Provider Demographics
NPI:1801120035
Name:EMERGENCY NEUROSURGERY SERVICES MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:EMERGENCY NEUROSURGERY SERVICES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-771-3393
Mailing Address - Street 1:1301 SECRET RAVINE PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3096
Mailing Address - Country:US
Mailing Address - Phone:916-771-3393
Mailing Address - Fax:916-771-3445
Practice Address - Street 1:1301 SECRET RAVINE PKWY
Practice Address - Street 2:STE 200
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3096
Practice Address - Country:US
Practice Address - Phone:916-771-3393
Practice Address - Fax:916-771-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38223207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty