Basic Information
| Provider Information | |||||||||
| NPI: | 1316996564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13880 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191013880 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 8055645087 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134847301 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2006 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9732511132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | DD1910 | 01 | RAILROAD GRP # | OTHER | ZZZ64832Z | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER | 1316996564 | 05 | CA | MEDICAID | GR0094163 | 05 | CA | MEDICAID |