Basic Information
| Provider Information | |||||||||
| NPI: | 1891786240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDEN EMERGENCY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 734861 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606734861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002250953 | ||||||||
| FaxNumber: | 5629245830 | ||||||||
| Practice Location | |||||||||
| Address1: | 20103 LAKE CHABOT RD | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945465305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCWHORTER | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7068598998 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 001645 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.