Basic Information
| Provider Information | |||||||||
| NPI: | 1255537924 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED EMERGENCY SPECIALISTS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 N STAR WAY | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 695 N KELLOGG ST | ||||||||
| Address2: | EMERGENCY DEPT. | ||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614012807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093438131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3096915573 | ||||||||
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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 | 04832042 | 01 | IL | BLUE SHIELD | OTHER |