Basic Information
Provider Information | |||||||||
NPI: | 1740230390 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JJ&R EMERGENCY MEDICAL GROUP OF CALIFORNIA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4551 GLENCOE AVE | ||||||||
Address2: | SUITE 260 | ||||||||
City: | MARINA DEL REY | ||||||||
State: | CA | ||||||||
PostalCode: | 902926385 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103012030 | ||||||||
FaxNumber: | 3103065247 | ||||||||
Practice Location | |||||||||
Address1: | 450 GREENFIELD AVE | ||||||||
Address2: | EMERGENCY DEPARTMENT | ||||||||
City: | HANFORD | ||||||||
State: | CA | ||||||||
PostalCode: | 932303513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5595829000 | ||||||||
FaxNumber: | 5595847401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 09/26/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STAUM | ||||||||
AuthorizedOfficialFirstName: | BARRY | ||||||||
AuthorizedOfficialMiddleName: | B. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 3103012030 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G28196 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.