Healthcare Provider Details

I. General information

NPI: 1164715645
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: 05/17/2011
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 MOUNTAIN RANCH RD
SAN ANDREAS CA
95249-9707
US

IV. Provider business mailing address

3916 STATE ST #300
SANTA BARBARA CA
93105-5602
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-3521
  • Fax:
Mailing address:
  • Phone:
  • Fax: 805-564-5087

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