Provider Demographics
NPI:1730104498
Name:EMERGENCY DEPARTMENT PHYSICIANS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EMERGENCY DEPARTMENT PHYSICIANS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-557-0135
Mailing Address - Street 1:2550 NORTH HOLLYWOOD WAY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-5015
Mailing Address - Country:US
Mailing Address - Phone:818-557-0135
Mailing Address - Fax:818-557-1394
Practice Address - Street 1:1225 WILSHIRE BOULEVARD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2395
Practice Address - Country:US
Practice Address - Phone:213-482-2741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014357Medicaid
CACC6638OtherGOOD SAM RAILROAD
CAZZZ42800ZOtherGOOD SAM BLUE SHIELD
CACC6638OtherGOOD SAM RAILROAD