Provider Demographics
NPI:1316996564
Name:PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Entity type:Organization
Organization Name:PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-251-1132
Mailing Address - Street 1:PO BOX 13880
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-3880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:805-564-5087
Practice Address - Street 1:2131 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1901
Practice Address - Country:US
Practice Address - Phone:213-484-7301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD1910OtherRAILROAD GRP #
CAZZZ64832ZOtherBLUE SHIELD OF CALIFORNIA
CA1316996564Medicaid
CAGR0094163Medicaid
CAHW18098AMedicare PIN