Basic Information
Provider Information
NPI: 1295913358
EntityType: 2
ReplacementNPI:  
OrganizationName: SOUTHERN TULARE MEDICAL GROUP
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Mailing Information
Address1: PO BOX 7096
Address2:  
City: STOCKTON
State: CA
PostalCode: 952670096
CountryCode: US
TelephoneNumber: 2099567725
FaxNumber: 2099567733
Practice Location
Address1: 465 W PUTNAM AVE
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City: PORTERVILLE
State: CA
PostalCode: 932573320
CountryCode: US
TelephoneNumber: 5597841110
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Other Information
ProviderEnumerationDate: 01/31/2008
LastUpdateDate: 01/31/2008
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AuthorizedOfficialLastName: ATTOH
AuthorizedOfficialFirstName: MICHAEL
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AuthorizedOfficialTitleorPosition: MD
AuthorizedOfficialTelephone: 5597841110
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IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208M00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansHospitalist 
207RH0003X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology

ID Information
IDTypeStateIssuerDescription
ZZZ07552Z01CABLUE SHIELD OF CALIFORNIAOTHER
GR009524005CA MEDICAID


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