Basic Information
| Provider Information | |||||||||
| NPI: | 1124322847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JELLICO EMERGENCY PHYSICIANS MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11769 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926851769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624680227 | ||||||||
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| Practice Location | |||||||||
| Address1: | 188 HOSPITAL LN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237847252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2011 | ||||||||
| LastUpdateDate: | 10/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | MARON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9252255837 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 1522627 | 05 | TN | MEDICAID | 7100162540 | 05 | KY | MEDICAID |