Basic Information
| Provider Information | |||||||||
| NPI: | 1104877315 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JJ&R EMERGENCY MEDICAL GROUP OF CALIFORNIA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1700 EAST WALNUT AVENUE | ||||||||
| Address2: | #250 | ||||||||
| City: | EL SAGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902452605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103012030 | ||||||||
| FaxNumber: | 3103065247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 E CESAR E CHAVEZ AVE | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900332414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232685000 | ||||||||
| FaxNumber: | 3238818605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STAUM | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT &CEO | ||||||||
| AuthorizedOfficialTelephone: | 3103012030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G28196 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.