Basic Information
Provider Information | |||||||||
NPI: | 1871535286 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTERCOMMUNITY EMERGENCY MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4419 | ||||||||
Address2: |   | ||||||||
City: | WOODLAND HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913654419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005066895 | ||||||||
FaxNumber: | 8185872493 | ||||||||
Practice Location | |||||||||
Address1: | 12401 WASHINGTON BLVD | ||||||||
Address2: |   | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906021006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626980811 | ||||||||
FaxNumber: | 8185872493 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRAMER | ||||||||
AuthorizedOfficialFirstName: | IAN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5626980811 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | GR0048670 | 05 | CA |   | MEDICAID | ZZZ27738Z | 01 | CA | BLUE SHIELD | OTHER | CU0753 | 01 | CA | RAILROAD MEDICARE | OTHER |