Basic Information
| Provider Information | |||||||||
| NPI: | 1396786026 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIX RIVERS EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 JANES RD | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268264 | ||||||||
| FaxNumber: | 7078268292 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 JANES RD | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268264 | ||||||||
| FaxNumber: | 7078268292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | VIRGIL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7078268264 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0094250 | 05 | CA | MEDICAID |