MEDICARE: HEMET EMERGENCY MED GROUP @ MENIFEE HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0013771	OTHER		MEDI-CAL
2	ZZZ30469Z	OTHER		BLUE SHIELD

General Provider Information

NPI Number	:	1265620090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEMET EMERGENCY MED GROUP @ MENIFEE HOSPITAL

Provider Business Mailing Address
First Line	:	FILE 57351
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90074-7351
Country	:	US
Telephone Number	:	800-819-3982
Fax Number	:

Provider Business Practice Location Address
First Line	:	28400 MCCALL BLVD
Second Line	:
City	:	SUN CITY
State	:	CA
Zip	:	92585-9658
Country	:	US
Telephone Number	:	909-679-8888
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PETER BOSS
Credential	:
Telephone Number	:	951-652-2811

Provider Enumeration Date	:	10/05/2007
Last Update Date	:	06/06/2009

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