Healthcare Provider Details

I. General information

NPI: 1164473443
Provider Name (Legal Business Name): JJ&R EMERGENCY MEDICAL GROUP OF CALIFORNIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SYCAMORE DR EMERGENCY DEPARTMENT
SIMI VALLEY CA
93065-1201
US

IV. Provider business mailing address

1700 EAST WALNUT AVENUE #250
EL SEGUNDO CA
90245-2605
US

V. Phone/Fax

Practice location:
  • Phone: 805-955-6000
  • Fax:
Mailing address:
  • Phone: 310-301-2030
  • Fax: 310-306-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG28196
License Number StateCA

VIII. Authorized Official

Name: BARRY B. STAUM
Title or Position: PRESIDENT & CEO
Credential: M.D.
Phone: 310-301-2030