| Name: | Island Medical Alabama, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 06 Feb 2008 (17 years ago) |
| Entity Number: | 000-416-379 |
| Register Number: | 000416379 |
| Historical Names: |
Pegasus Emergency Group Alabama, LLC
|
| County: | Montgomery |
| Place of Formation: | Jefferson County |
| Registered Office Street Address: | 641 SOUTH LAWRENCE STREETMONTGOMERY, AL 36104 |
| Registered Office Street Address ZIP Code: | 36104 |
Activities
PROVIDE EMERGENCY ROOM PHYSICIAN STAFFING TO HOSPITALS
| Unique Entity ID | Expiration Date | Physical Address | Mailing Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| UX99ELV5WWJ5 | 2022-07-17 | 1912 AL HIGHWAY 157, CULLMAN, AL, 35058, 0609, USA | 12420 MILESTONE CENTER DRIVE, SUITE 200, GERMANTOWN, MD, 20874, USA | |||||||||||||||||||||||||||||||||||||
|
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| Congressional District | 04 |
| Activation Date | 2021-06-24 |
| Initial Registration Date | 2021-06-17 |
| Entity Start Date | 2014-08-06 |
| Fiscal Year End Close Date | May 31 |
Points of Contacts
| Electronic Business | |
|---|---|
| Title | PRIMARY POC |
| Name | TOLULOPE HOLLOWAY |
| Role | RCM OPS ASSOCIATE |
| Address | 12420 MILESTONE CENTER DRIVE, SUITE 200, BEACHWOOD, OH, 44122, USA |
| Government Business | |
|---|---|
| Title | PRIMARY POC |
| Name | TOLULOPE HOLLOWAY |
| Role | RCM OPS ASSOCIATE |
| Address | 12420 MILESTONE CENTER DRIVE, SUITE 200, BEACHWOOD, OH, 44122, USA |
| Past Performance | Information not Available |
|---|
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1104097666 | 2008-03-12 | 2023-02-24 | 4535 DRESSLER RD NW, CANTON, OH, 447182545, US | 1912 AL HIGHWAY 157, CULLMAN, AL, 350580609, US | |||||||||||||||||||
|
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| Phone | +1 330-994-4409 |
| Fax | 3304928489 |
| Phone | +1 844-474-4019 |
Authorized person
| Name | MELISSA REESE |
| Role | PROVIDER ENROLLMENT OFFICER |
| Phone | 8556870618 |
Taxonomy
| Taxonomy Code | 207P00000X - Emergency Medicine Physician |
| State | AL |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| CORPORATION SERVICE COMPANY INC | Agent | 251 LITTLE FALLS DRIVEWILMINGTON, DE 19808 |
| Name | Role | Address |
|---|---|---|
| SPECTOR, EDWARD | Member | No data |
| SAMA, MICHAEL | Member | No data |
| RUZICH, JEFFERY | Member | No data |
| JUSTIN, ELLIOT | Member | 1007 E MAIN ST STE 300BOZEMAN, MT 59715 |
| Event Date | Event Type | Old Value | New Value |
|---|---|---|---|
| 2015-09-22 | Name Change | Pegasus Emergency Group Alabama, LLC | Island Medical Alabama, LLC |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
