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NPI Code Detail

MEDICARE: PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC

MEDICARE: PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
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
1363A00000XPhysician Assistant
2363L00000XNurse Practitioner
3207P00000XEmergency Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1DD1910OTHERRAILROAD GRP #
2ZZZ64832ZOTHERCABLUE SHIELD OF CALIFORNIA
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1316996564
Entity Type Code : Organization
Provider Name (Legal Business Name) : PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Provider Business Mailing Address
First Line : PO BOX 13880
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19101-3880
Country : US
Telephone Number :
Fax Number : 805-564-5087
Provider Business Practice Location Address
First Line : 2131 W 3RD ST
Second Line :
City : LOS ANGELES
State : CA
Zip : 90057-1901
Country : US
Telephone Number : 213-484-7301
Fax Number :
Authorized Official
Title or Position : OFFICER
Name : KATHY KONDAS
Credential :
Telephone Number : 973-251-1132
Provider Enumeration Date : 05/07/2006
Last Update Date : 04/09/2021

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