Provider Demographics
NPI:1225289135
Name:PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Entity Type:Organization
Organization Name:PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-251-1132
Mailing Address - Street 1:PO BOX 98644
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8644
Mailing Address - Country:US
Mailing Address - Phone:800-355-0808
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:820 E MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3004
Practice Address - Country:US
Practice Address - Phone:760-957-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225289135Medicaid
CABC551Medicare PIN