1962453860 NPI number — EMERGENCY MEDICINE ASSOCIATES PC

Table of content: (NPI 1962453860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962453860 NPI number — EMERGENCY MEDICINE ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERGENCY MEDICINE ASSOCIATES PC
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:
1962453860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742997
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-2997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-280-1773
Provider Business Mailing Address Fax Number:
781-280-1814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NE 92ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-3225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-514-2000
Provider Business Practice Location Address Fax Number:
360-514-6820
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORECKI
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MD/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
360-514-2142

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  601287343 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QE0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7128507 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 278137 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE1747 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 012411400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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