Provider Demographics
NPI:1598093262
Name:EASTERN MEDICAL CENTER PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EASTERN MEDICAL CENTER PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:EASTERN MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LI
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-972-8966
Mailing Address - Street 1:2930 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-4210
Mailing Address - Country:US
Mailing Address - Phone:916-972-8966
Mailing Address - Fax:916-972-8916
Practice Address - Street 1:2930 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-4210
Practice Address - Country:US
Practice Address - Phone:916-972-8966
Practice Address - Fax:916-972-8916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65618207Q00000X
CAA83360207R00000X
CAA73749208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1134230220OtherNPI
CA1912973520OtherNPI
CA1710959523OtherNPI
CA1710959523OtherNPI
CAG98271Medicare UPIN
CA00A656180Medicare PIN
CA1134230220OtherNPI