Provider Demographics
NPI:1891994174
Name:PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Entity Type:Organization
Organization Name:PREMIER EMERGENCY PHYSICIANS OF CALIFORNIA MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-251-1132
Mailing Address - Street 1:PO BOX 37655
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-0655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3320
Practice Address - Country:US
Practice Address - Phone:559-784-8886
Practice Address - Fax:559-791-4802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADH0325OtherRAILROAD
CAGR0094164Medicaid
CA1891994174Medicaid
CAZZZ62867ZOtherBLUE SHIELD OF CALIFORNIA
CAZZZ05890ZMedicare PIN