MEDICARE: CALIFORNIA EMERGENCY PHYSICIANS MEDICAL GROUP, A PROFESSIONAL CORP.

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1982076055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA EMERGENCY PHYSICIANS MEDICAL GROUP, A PROFESSIONAL CORP.

Provider Business Mailing Address
First Line	:	1601 CUMMINS DR STE D
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95358-6411
Country	:	US
Telephone Number	:	209-491-7710
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 NW HILL AVE
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471-1672
Country	:	US
Telephone Number	:	541-672-1631
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THEOPHILE KOURY
Credential	:	M.D
Telephone Number	:	510-350-2600

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	01/30/2020

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