Basic Information
| Provider Information | |||||||||
| NPI: | 1982650271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY EMERGENCY MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 N SEPULVEDA BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902666861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103792134 | ||||||||
| FaxNumber: | 3103794856 | ||||||||
| Practice Location | |||||||||
| Address1: | 2740 M ST | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953402813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093846480 | ||||||||
| FaxNumber: | 2093846710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | BELL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3103792134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0068932 | 05 | CA | MEDICAID |