Healthcare Provider Details

I. General information

NPI: 1306126578
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: 08/19/2011
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E. LOCUST ST.
LONE PINE CA
93545
US

IV. Provider business mailing address

PO BOX 98554
LAS VEGAS NV
89193-8554
US

V. Phone/Fax

Practice location:
  • Phone: 760-876-5501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

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