Healthcare Provider Details

I. General information

NPI: 1063601946
Provider Name (Legal Business Name): EMERALD ISLE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 BROCKTON AVE STE 104
RIVERSIDE CA
92501-3442
US

IV. Provider business mailing address

4121 BROCKTON AVE STE 104
RIVERSIDE CA
92501-3442
US

V. Phone/Fax

Practice location:
  • Phone: 951-778-0032
  • Fax:
Mailing address:
  • Phone: 951-778-0032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA46400
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA46400
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA46400
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberA46400
License Number StateCA

VIII. Authorized Official

Name: DR. BERTRAND DE SILVA
Title or Position: OWNER
Credential: M.D.
Phone: 714-444-0440