Basic Information
| Provider Information | |||||||||
| NPI: | 1609888940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT JOHNS EMERGENCY MEDICINE SPECIALISTS INC A MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4419 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913654419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183409988 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2121 SANTA MONICA BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108295511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEITZ | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3105827089 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/10/2020 | ||||||||
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 | GR0062990 | 05 | CA | MEDICAID |