Provider Demographics
NPI:1609887322
Name:EXECUTIVE MEDICAL & SURGICAL ASSOC. INC.
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL & SURGICAL ASSOC. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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 1:1040 S. MT. VERNON AVE.
Mailing Address - Street 2:#G350
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324
Mailing Address - Country:US
Mailing Address - Phone:909-824-2422
Mailing Address - Fax:909-824-8234
Practice Address - Street 1:900 E WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4192
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:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty