Basic Information
| Provider Information | |||||||||
| NPI: | 1356904577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARSHALL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45680 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941450680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306262618 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3581 PALMER DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956828237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306727000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2019 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | SANGUINETTI-WEISHAAR | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5306262770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | ZZZ00439Z | 05 | CA | MEDICAID |