Provider Demographics
NPI:1144775016
Name:EXECUTIVE MEDICAL & SURGICAL ASSOCIATES INC.
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL & SURGICAL ASSOCIATES INC.
Other - Org Name:BERGEY SPINE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:DALENE
Authorized Official - Last Name:BERGEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-824-2422
Mailing Address - Street 1:81880 DOCTOR CARREON BLVD STE C212
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5519
Mailing Address - Country:US
Mailing Address - Phone:760-775-9400
Mailing Address - Fax:760-775-3000
Practice Address - Street 1:900 E WASHINGTON ST STE 300
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-8182
Practice Address - Country:US
Practice Address - Phone:909-824-2422
Practice Address - Fax:909-824-8234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72267174400000X
CAA89036174400000X
CAPA21389363A00000X
CAPA 52156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G53228Medicare UPIN