Basic Information
| Provider Information | |||||||||
| NPI: | 1689636730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BURBANK EMERGENCY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004778909 | ||||||||
| FaxNumber: | 4057513183 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S BUENA VISTA ST | ||||||||
| Address2: | EM DEPT | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188435111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | SCHWARZMAN | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | SIMON | ||||||||
| AuthorizedOfficialTitleorPosition: | EMERGENCY DEPT. MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8188480552 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ72788Z | 01 | MEDI CAL | OTHER | N49 | 01 | CALOPTIMA | OTHER | ZZZ72788Z | 01 | BLUE SHIELD | OTHER | C41068 | 01 | RAIL ROAD MEDICARE | OTHER | 05D0971295 | 01 | CLIA WAIVER | OTHER | 2956715 | 01 | MEDI CAL AEVS | OTHER |