=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811395585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVE CREEK EMERGENCY PHYSICIANS MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2014
-----------------------------------------------------
Last Update Date | 08/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16000 JOHNSTON MEMORIAL DR
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24211-7664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-258-1100
-----------------------------------------------------
Fax | 276-258-1125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 930
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-0930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-447-0296
-----------------------------------------------------
Fax | 626-447-6057
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVEN P. MARON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 626-447-0296
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------