Basic Information
| Provider Information | |||||||||
| NPI: | 1154631703 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARTON HEALTHCARE SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BARTON FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435659 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 3RD ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961503485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435660 | ||||||||
| FaxNumber: | 5305421619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2010 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/22/2015 | ||||||||
| NPIReactivationDate: | 04/19/2017 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DERBY | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5305435841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 0300000676 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.