Basic Information
| Provider Information | |||||||||
| NPI: | 1407956899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA CARDIAC SURGEONS - A MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3838 SAN DIMAS ST | ||||||||
| Address2: | SUITE A-100 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933012284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613278538 | ||||||||
| FaxNumber: | 6613275432 | ||||||||
| Practice Location | |||||||||
| Address1: | 3838 SAN DIMAS ST | ||||||||
| Address2: | SUITE A-100 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933012284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613278538 | ||||||||
| FaxNumber: | 6613275432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 04/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | VENESSA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6613278538 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 2086S0129X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZZZ42099Z | 01 | BLUE SHIELD GROUP ID | OTHER | GR0060120 | 05 | CA | MEDICAID |