Provider Demographics
NPI:1962512384
Name:GLENN EMERGENCY PHYSICIANS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:GLENN EMERGENCY PHYSICIANS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:925-482-2811
Mailing Address - Street 1:PO BOX 661972
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-1972
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:1133 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-2601
Practice Address - Country:US
Practice Address - Phone:530-934-1840
Practice Address - Fax:530-934-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
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
CAGR0100490Medicaid
CAGR0100490Medicaid