=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487130167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCK HOLLOW CRITICAL CARE MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2018
-----------------------------------------------------
Last Update Date | 08/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 N VERMONT AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-413-3000
-----------------------------------------------------
Fax | 386-274-7801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11181
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32120-1181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-274-7800
-----------------------------------------------------
Fax | 386-274-7801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVEN P MORAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 925-482-8233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------