Basic Information
| Provider Information | |||||||||
| NPI: | 1730496688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND EMPIRE EMERGENCY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660907 | ||||||||
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| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910660907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264470296 | ||||||||
| FaxNumber: | 6264476057 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 W ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917406207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268526119 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2010 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | MARON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6264470296 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 1730496688 | 05 | CA | MEDICAID |