Basic Information
| Provider Information | |||||||||
| NPI: | 1285670406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MMC EMERGENCY PHYSICIANS MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94913 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731434913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009623303 | ||||||||
| FaxNumber: | 8057393064 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393200 | ||||||||
| FaxNumber: | 8057393064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | COTE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8057484502 | ||||||||
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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 | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0054630 | 05 | CA | MEDICAID |