Basic Information
| Provider Information | |||||||||
| NPI: | 1215021936 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUDHA G MADABHUSHI MD INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ACCLAIM MEDICAL CARE INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 661 | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925460661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519257179 | ||||||||
| FaxNumber: | 9517652855 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 W LATHAM AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925434106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519257170 | ||||||||
| FaxNumber: | 9519257027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | MADABHUSHI | ||||||||
| AuthorizedOfficialFirstName: | SUDHA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9519296260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A70292 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0104430 | 05 | CA | MEDICAID |