Basic Information
| Provider Information | |||||||||
| NPI: | 1720028574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA EMERGENCY PHYSC MED GRP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL STREET | ||||||||
| Address2: | STE 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 219 NORTH JACKSON AVENUE | ||||||||
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| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4087292841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | KOURY | ||||||||
| AuthorizedOfficialFirstName: | THEOPHILE | ||||||||
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| AuthorizedOfficialTitleorPosition: | M.D | ||||||||
| AuthorizedOfficialTelephone: | 5103502600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.