Basic Information
| Provider Information | |||||||||
| NPI: | 1629006655 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN SOLANO EMERGENCY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634719 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452634719 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945892574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259241600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | CARVOLTH | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9259241600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | DC2287 | 01 | CA | MEDICARE RR | OTHER | GR0095980 | 05 | CA | MEDICAID | ZZZ09370Z | 01 | CA | BS CALIFORNIA | OTHER |