Provider Demographics
NPI:1083998173
Name:PROVIDENT HOSPITALIST ASSOCIATES, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PROVIDENT HOSPITALIST ASSOCIATES, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUJAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-351-4566
Mailing Address - Street 1:1191 MAGNOLIA AVE
Mailing Address - Street 2:SUITE D #248
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3215
Mailing Address - Country:US
Mailing Address - Phone:951-736-6325
Mailing Address - Fax:
Practice Address - Street 1:800 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3420
Practice Address - Country:US
Practice Address - Phone:951-737-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63079207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty