Basic Information
| Provider Information | |||||||||
| NPI: | 1205862489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILL PULMONARY & CRITICAL CARE CONSULTANTS MEDICAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 959 E WALNUT ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911061451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267955118 | ||||||||
| FaxNumber: | 6267952716 | ||||||||
| Practice Location | |||||||||
| Address1: | 959 E WALNUT ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911061451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267955118 | ||||||||
| FaxNumber: | 6267952716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KURE | ||||||||
| AuthorizedOfficialFirstName: | TANIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6267955118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RC0200X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ72449Z | 05 | CA | MEDICAID |