Basic Information
| Provider Information | |||||||||
| NPI: | 1669688339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDWARD S. COLBY | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 57430 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900747430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008192424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 438 W LAS TUNAS DR | ||||||||
| Address2: | |||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917761216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262895457 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCMANN | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 5095354370 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G22095 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G220950 | 05 | CA | MEDICAID |