Basic Information
| Provider Information | |||||||||
| NPI: | 1952392375 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALTAMONT EMERGENCY PHYSICIANS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 GLASS LN STE C | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 N TRACY BLVD | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953763451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | CRAWFORD | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2093422300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34916 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ22800Z | 01 | CA | BLUE SHIELD | OTHER | GR0044000 | 05 | CA | MEDICAID |