Basic Information
| Provider Information | |||||||||
| NPI: | 1881995272 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN SIERRA EMERGENCY PHYSICIANS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4535 DRESSLER RD NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556870618 | ||||||||
| FaxNumber: | 3304938677 | ||||||||
| Practice Location | |||||||||
| Address1: | 29100 HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | LAKE ARROWHEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923529706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556870618 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | MARON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8556870618 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/06/2022 | ||||||||
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 | 1881995272 | 05 | CA | MEDICAID |