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General NPI Number Information
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NPI Number | 1083998173
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Entity Type | Organization
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Legal Business Name | PROVIDENT HOSPITALIST ASSOCIATES, A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 10/06/2011
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Last Update Date | 10/10/2011
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Provider Practice Location Address
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Address Line | 800 S MAIN ST
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City | CORONA
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State | CA
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Zip | 92882-3420
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Country | US
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Telephone | 951-737-4343
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Fax |
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Provider Business Mailing Address
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Address Line | 1191 MAGNOLIA AVE SUITE D #248
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City | CORONA
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State | CA
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Zip | 92879-3215
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Country | US
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Telephone | 951-736-6325
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SUNIL SUJAN
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Credential | M.D.
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Telephone | 310-351-4566
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A63079
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License Number State | CA
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