Healthcare Provider Details

I. General information

NPI: 1982907770
Provider Name (Legal Business Name): GRAPEVINE EMERGENCY PHYSICIANS MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 07/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N TUSTIN AVE
SANTA ANA CA
92705-3502
US

IV. Provider business mailing address

PO BOX 1429
ARCADIA CA
91077-1429
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-3331
  • Fax:
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-447-6057

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: STEVEN P. MARON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-447-0296