Basic Information
| Provider Information | |||||||||
| NPI: | 1295994812 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN EMERGENCY PHYSICIANS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3023 | ||||||||
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| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917737023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264470296 | ||||||||
| FaxNumber: | 6266231227 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 EASTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960931229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306235541 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | MARON | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6264470296 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1295994812 | 05 | CA | MEDICAID |