Provider Demographics
NPI:1871738823
Name:PIKE EMERGENCY MEDICINE LLC
Entity type:Organization
Organization Name:PIKE EMERGENCY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:K
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-754-5531
Mailing Address - Street 1:PO BOX 10739
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-0739
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:2305 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:LOUISIANA
Practice Address - State:MO
Practice Address - Zip Code:63353-2559
Practice Address - Country:US
Practice Address - Phone:573-754-5531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1525Medicare PIN