Basic Information
| Provider Information | |||||||||
| NPI: | 1750364865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIN EMERGENCY PHYSICIANS MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4419 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913654419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183409988 | ||||||||
| FaxNumber: | 8184447214 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 ROWLAND WAY | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949455009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152091300 | ||||||||
| FaxNumber: | 4152091351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | BODONY | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4152091300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0505346 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0086760 | 05 | CA | MEDICAID | ZZZ64077Z | 01 | CA | BLUE SHIELD | OTHER |