1780692632 NPI number — BERKELEY EMERGENCY MEDICAL GROUP, INC.

Table of content: (NPI 1780692632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780692632 NPI number — BERKELEY EMERGENCY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERKELEY EMERGENCY MEDICAL GROUP, INC.
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:
1780692632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 920139
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:
75392-0139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-447-0296
Provider Business Mailing Address Fax Number:
626-623-1227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2450 ASHBY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94705-2067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-346-2211
Provider Business Practice Location Address Fax Number:
925-962-1801
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SORNSIN
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
925-303-6255

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0065880 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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