| Name: | Island Medical Coosa Valley, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Merged |
| Date of registration: | 18 Aug 2009 (15 years ago) |
| Entity Number: | 000-437-463 |
| Register Number: | 000437463 |
| Historical Names: |
Pegasus Emergency Group Coosa Valley, LLC
|
| County: | Montgomery |
| Place of Formation: | Madison County |
| Registered Office Street Address: | 641 SOUTH LAWRENCE STREETMONTGOMERY, AL 36104 |
| Registered Office Street Address ZIP Code: | 36104 |
Activities
PROVIDE MEDICAL SERVICES TO MEDICAL FACILITIES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1083948558 | 2009-09-30 | 2017-02-03 | PO BOX 92991, CLEVELAND, OH, 441942991, US | 205 MARENGO ST, FLORENCE, AL, 356306033, US | |||||||||||||||||||||||
|
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| Phone | +1 877-716-2447 |
| Fax | 3306565901 |
| Phone | +1 256-768-9191 |
Authorized person
| Name | DR. NEIL E SCHAMBAN |
| Role | MD |
| Phone | 2567372106 |
Taxonomy
| Taxonomy Code | 207P00000X - Emergency Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 115938 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| JUSTIN, ELLIOT | Member | 1007 E MAIN ST STE 300BOZEMAN, MT 59715 |
| SCHAMBAN, NEIL | Member | 1007 EAST MAIN STREET SUITE 300BOZEMAN, MT 59715 |
| ASHAR, TOM | Member | 121 DEVON DRIVEHOMEWOOD, AL 35209 |
| Name | Role | Address |
|---|---|---|
| CORPORATION SERVICE COMPANY INC | Agent | 251 LITTLE FALLS DRIVEWILMINGTON, DE 19808 |
| Event Date | Event Type | Old Value | New Value |
|---|---|---|---|
| 2015-09-21 | Name Change | Pegasus Emergency Group Coosa Valley, LLC | Island Medical Coosa Valley, LLC |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
