Basic Information
| Provider Information | |||||||||
| NPI: | 1285625509 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLEASANTON EMERGENCY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4155 | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917738155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264470296 | ||||||||
| FaxNumber: | 6266231227 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 W LAS POSITAS BLVD | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | KAN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9255192089 | ||||||||
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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 | 040027 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0094321 | 05 | CA | MEDICAID | ZZZ08094Z | 01 | CA | BLUE SHIELD | OTHER |