Basic Information
| Provider Information | |||||||||
| NPI: | 1245384742 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARSHALL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARSHALL OB/GYN CAMERON PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45680 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941450680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306262920 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3501 PALMER DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956828276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267061 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELDRIDGE | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5306262780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.