Basic Information
| Provider Information | |||||||||
| NPI: | 1922058221 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 S PALAFOX ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325025960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004447009 | ||||||||
| FaxNumber: | 8003053233 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 N 1ST ST | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609224115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9732511132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ64207Z | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER | GR0094162 | 05 | CA | MEDICAID |