Provider Demographics
NPI:1972539039
Name:RIVERSIDE EMERGENCY PHYSICIANS MEDICAL GROUP
Entity Type:Organization
Organization Name:RIVERSIDE EMERGENCY PHYSICIANS MEDICAL GROUP
Other - Org Name:RIVERSIDE EMERGENCY PHYSICIANS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-447-0296
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:800-749-4560
Mailing Address - Fax:405-755-5283
Practice Address - Street 1:3865 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3919
Practice Address - Country:US
Practice Address - Phone:951-898-0823
Practice Address - Fax:951-352-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094070Medicaid
CAGR0094070Medicaid