Provider Demographics
NPI:1154571404
Name:WATSONVILLE EMERGENCY MEDICAL GROUP
Entity type:Organization
Organization Name:WATSONVILLE EMERGENCY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:V
Authorized Official - Last Name:HAJDUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-763-0535
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:75 NIELSON ST
Practice Address - Street 2:EM DEPARTMENT
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2468
Practice Address - Country:US
Practice Address - Phone:831-761-5613
Practice Address - Fax:405-751-3183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ55932YOtherBLUE SHIELD
61420880OtherDEPT OF LABOR
CA1154571404Medicaid
CADO7379Medicare PIN
CAAY828Medicare PIN