Basic Information
| Provider Information | |||||||||
| NPI: | 1811395585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COVE CREEK EMERGENCY PHYSICIANS MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 930 | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917730930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264470296 | ||||||||
| FaxNumber: | 6264476057 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762581100 | ||||||||
| FaxNumber: | 2762581125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2014 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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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 | 1811395585 | 05 | VA | MEDICAID |