Basic Information
Provider Information | |||||||||
NPI: | 1235310335 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF EMANUEL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
Address2: |   | ||||||||
City: | MADERA | ||||||||
State: | CA | ||||||||
PostalCode: | 936368761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5593535700 | ||||||||
FaxNumber: | 5593535708 | ||||||||
Practice Location | |||||||||
Address1: | 825 DELBON AVE | ||||||||
Address2: |   | ||||||||
City: | TURLOCK | ||||||||
State: | CA | ||||||||
PostalCode: | 953822016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2096645065 | ||||||||
FaxNumber: | 2096645067 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2007 | ||||||||
LastUpdateDate: | 11/16/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DIAZ | ||||||||
AuthorizedOfficialFirstName: | RALPH | ||||||||
AuthorizedOfficialMiddleName: | P. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5593535700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   | 208000000X |   | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | GR007868G | 05 | CA |   | MEDICAID |