Provider Demographics
NPI:1891726816
Name:COLUSA EMERGENCY PHYSICIANS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:COLUSA EMERGENCY PHYSICIANS MEDICAL GROUP, INC.
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:626-447-0296
Mailing Address - Street 1:PO BOX 660788
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0788
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:199 E WEBSTER ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2954
Practice Address - Country:US
Practice Address - Phone:530-458-3283
Practice Address - Fax:530-458-3215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093760Medicaid
CAZZZ24293ZMedicare PIN