Provider Demographics
NPI:1003238510
Name:EBMD, P.C.
Entity Type:Organization
Organization Name:EBMD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENRICO
Authorized Official - Middle Name:URO
Authorized Official - Last Name:BALCOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-545-1121
Mailing Address - Street 1:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91031-1526
Mailing Address - Country:US
Mailing Address - Phone:949-545-1121
Mailing Address - Fax:949-258-5551
Practice Address - Street 1:5353 G ST
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5249
Practice Address - Country:US
Practice Address - Phone:909-590-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA633632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A633630Medicaid
CA00A633630Medicaid