Provider Demographics
NPI:1184927964
Name:PALM DRIVE EMERGENCY PHYSICIANS MEDICAL GROUP INC
Entity type:Organization
Organization Name:PALM DRIVE EMERGENCY PHYSICIANS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-447-0296
Mailing Address - Street 1:PO BOX 1339
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91077-1339
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:1250 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:424-259-8401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184927964Medicaid
CAEO723AMedicare PIN