Provider Demographics
NPI:1891786240
Name:EDEN EMERGENCY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:EDEN EMERGENCY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MCWHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-859-8998
Mailing Address - Street 1:PO BOX 734861
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-4861
Mailing Address - Country:US
Mailing Address - Phone:800-225-0953
Mailing Address - Fax:562-924-5830
Practice Address - Street 1:20103 LAKE CHABOT RD
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5305
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:2005-11-03
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA001645207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014570Medicaid
CAZZZ921712OtherBLUE SHIELD
CAGR0014570Medicaid