Provider Demographics
NPI:1780066076
Name:PACIFIC PARADISE EMERGENCY PHYSICIANS MEDICAL GROUP INC
Entity type:Organization
Organization Name:PACIFIC PARADISE EMERGENCY PHYSICIANS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:626-447-0296
Mailing Address - Street 1:PO BOX 509015
Mailing Address - Street 2:DEPARTMENT # WS248
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-9015
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:2400 E 4TH ST
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2026
Practice Address - Country:US
Practice Address - Phone:619-470-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780066076OtherMEDI-CAL
CA1780066076OtherMEDI-CAL