Provider Demographics
NPI:1124322847
Name:JELLICO EMERGENCY PHYSICIANS MEDICAL GROUP PC
Entity type:Organization
Organization Name:JELLICO EMERGENCY PHYSICIANS MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-225-5837
Mailing Address - Street 1:PO BOX 11769
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1769
Mailing Address - Country:US
Mailing Address - Phone:562-468-0227
Mailing Address - Fax:
Practice Address - Street 1:188 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4400
Practice Address - Country:US
Practice Address - Phone:423-784-7252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522627Medicaid
KY7100162540Medicaid
KY7100162540Medicaid