Provider Demographics
NPI:1558432385
Name:HOLLISTER EMERGENCY PHYSICIANS, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HOLLISTER EMERGENCY PHYSICIANS, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ISCOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-401-2386
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:STE 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:469-401-2386
Mailing Address - Fax:
Practice Address - Street 1:911 SUNSET DR
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5602
Practice Address - Country:US
Practice Address - Phone:831-636-2640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207P00000X
363A00000X, 363L00000X
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
CA=========OtherCALIFORNIA BLUE CROSS
CA=========OtherCHAMPUS