Basic Information
Provider Information | |||||||||
NPI: | 1033391313 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PACIFIC MED & NEPHROLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PACIFIC MEDICAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 736 ROUTE 4 | ||||||||
Address2: | SUITE 103 | ||||||||
City: | SINAJANA | ||||||||
State: | GU | ||||||||
PostalCode: | 96910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6716497232 | ||||||||
FaxNumber: | 6716497233 | ||||||||
Practice Location | |||||||||
Address1: | 736 ROUTE 4 | ||||||||
Address2: | SUITE 103 | ||||||||
City: | SINAJANA | ||||||||
State: | GU | ||||||||
PostalCode: | 96910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6716497232 | ||||||||
FaxNumber: | 6716497233 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2007 | ||||||||
LastUpdateDate: | 10/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MADDAH | ||||||||
AuthorizedOfficialFirstName: | MERSEDEH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6716497232 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 261QM1300X | GU | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.