Healthcare Provider Details

I. General information

NPI: 1225289135
Provider Name (Legal Business Name): PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E MOUNTAIN VIEW ST
BARSTOW CA
92311-3004
US

IV. Provider business mailing address

PO BOX 98644
LAS VEGAS NV
89193-8644
US

V. Phone/Fax

Practice location:
  • Phone: 760-957-3030
  • Fax:
Mailing address:
  • Phone: 800-355-0808
  • Fax: 610-834-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132