Basic Information
| Provider Information | |||||||||
| NPI: | 1104871961 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHANDLER EMERGENCY MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | PREMIER EMERGENCY MEDICAL SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 96328 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731436328 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1955 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807283000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | COWARD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9548382371 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 785298 | 05 | AZ | MEDICAID |