Basic Information
Provider Information | |||||||||
NPI: | 1497700090 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CEP AMERICA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 POWELL ST | ||||||||
Address2: | STE 900 | ||||||||
City: | EMERYVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 946081826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103502600 | ||||||||
FaxNumber: | 5108799100 | ||||||||
Practice Location | |||||||||
Address1: | 10401 W THUNDERBIRD BLVD | ||||||||
Address2: |   | ||||||||
City: | SUN CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 853513004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239777211 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 08/05/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOURY | ||||||||
AuthorizedOfficialFirstName: | THEOPHILE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | M.D COO | ||||||||
AuthorizedOfficialTelephone: | 5103502600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CALIFORNIA EMERGENCY PHYSICIANS MEDICAL GROUP | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 089337 | 05 | AZ |   | MEDICAID |