Healthcare Provider Details

I. General information

NPI: 1699111617
Provider Name (Legal Business Name): EMERE MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S SAN MATEO DR SUITE 202
SAN MATEO CA
94401-3819
US

IV. Provider business mailing address

801 N 500 W SUITE 100
BOUNTIFUL UT
84010-6829
US

V. Phone/Fax

Practice location:
  • Phone: 855-433-5633
  • Fax:
Mailing address:
  • Phone: 801-617-2100
  • Fax: 801-208-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MARYAM RAHIMI
Title or Position: MEDICAL DIRECTOR / PHYSICIAN
Credential: DO
Phone: 855-433-5633