Basic Information
| Provider Information | |||||||||
| NPI: | 1063691467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC. - DEPT OF NEUROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | MB20 | ||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593536215 | ||||||||
| FaxNumber: | 5593536222 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | MB20 | ||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593536215 | ||||||||
| FaxNumber: | 5593536222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | KAJI | ||||||||
| AuthorizedOfficialFirstName: | DEVONNA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5593535700 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0804X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | GR0078689 | 05 | CA | MEDICAID | 1013968296 | 01 | CA | SMG GENERAL GROUP NPI | OTHER |