Provider Demographics
NPI:1629359864
Name:CALIFORNIA EMERGENCY PHYSICIAN MEDICAL GROUP
Entity Type:Organization
Organization Name:CALIFORNIA EMERGENCY PHYSICIAN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MID LEVEL PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:YEN
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:323-727-0205
Mailing Address - Street 1:615 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3528
Mailing Address - Country:US
Mailing Address - Phone:323-727-0205
Mailing Address - Fax:
Practice Address - Street 1:615 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3528
Practice Address - Country:US
Practice Address - Phone:323-727-0205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty