Provider Demographics
NPI:1629006655
Name:SOUTHERN SOLANO EMERGENCY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SOUTHERN SOLANO EMERGENCY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARVOLTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-924-1600
Mailing Address - Street 1:PO BOX 634719
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-4719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2574
Practice Address - Country:US
Practice Address - Phone:925-924-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC2287OtherMEDICARE RR
CAGR0095980Medicaid
CAZZZ09370ZOtherBS CALIFORNIA
CAZZZ29828ZMedicare PIN