Basic Information
| Provider Information | |||||||||
| NPI: | 1811055437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS EMERGENCY ROOM CORP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3028 | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917737028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8773462211 | ||||||||
| FaxNumber: | 6266231227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1460 G ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974774112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417264510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIDSON | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5417264510 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 275177 | 05 | OR | MEDICAID |