1285625509 NPI number — PLEASANTON EMERGENCY MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285625509 NPI number — PLEASANTON EMERGENCY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLEASANTON EMERGENCY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285625509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 920133
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75392-0143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-254-6697
Provider Business Mailing Address Fax Number:
626-623-1227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5555 W LAS POSITAS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLEASANTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-342-2300
Provider Business Practice Location Address Fax Number:
209-524-4240
Provider Enumeration Date:
11/04/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KAN
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
925-519-2089

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  040027 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ08094Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0094321 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".