Provider Demographics
NPI:1689665317
Name:PHOENIX EMERGENCY PHYSICIANS
Entity Type:Organization
Organization Name:PHOENIX EMERGENCY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUBBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-342-2300
Mailing Address - Street 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:13855 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2611
Practice Address - Country:US
Practice Address - Phone:209-342-2300
Practice Address - Fax:209-524-4240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27483207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ34666ZOtherBLUE SHIELD
CAGR0053820Medicaid
CAZZZ34666ZMedicare ID - Type Unspecified