Provider Demographics
NPI:1336299072
Name:EXECUTIVE MEDICAL & SURGICAL ASSOCIATES INC.
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL & SURGICAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-824-2422
Mailing Address - Street 1:PO BOX 894773
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90189-4773
Mailing Address - Country:US
Mailing Address - Phone:909-824-2422
Mailing Address - Fax:909-824-8234
Practice Address - Street 1:900 E WASHINGTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
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:2007-01-12
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04181ZMedicare PIN
CAG53228Medicare UPIN