Provider Demographics
NPI:1922058221
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 1:815 S PALAFOX ST
Mailing Address - Street 2:STE 300
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5960
Mailing Address - Country:US
Mailing Address - Phone:800-444-7009
Mailing Address - Fax:800-305-3233
Practice Address - Street 1:250 N 1ST ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1702
Practice Address - Country:US
Practice Address - Phone:760-922-4115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64207ZOtherBLUE SHIELD OF CALIFORNIA
CAGR0094162Medicaid
CADC6009Medicare PIN
CAZZZ31431ZMedicare PIN