Basic Information
| Provider Information | |||||||||
| NPI: | 1184823114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMARY CRITICAL CARE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 998 | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916030998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185092222 | ||||||||
| FaxNumber: | 8185092229 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S BUENA VISTA ST | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188435111 | ||||||||
| FaxNumber: | 8188430641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | GIPE | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8185092222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | G42382 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.