Provider Demographics
NPI:1114626017
Name:ANAHEIM EMERGENCY MEDICAL GROUP
Entity Type:Organization
Organization Name:ANAHEIM EMERGENCY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-898-0823
Mailing Address - Street 1:4401 W MEMORIAL RD STE 121
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1722
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-751-3183
Practice Address - Street 1:1111 W LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2804
Practice Address - Country:US
Practice Address - Phone:714-774-1450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty