Basic Information
Provider Information | |||||||||
NPI: | 1437248549 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ARBOR MEDICAL GROUP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1418 E MAIN ST | ||||||||
Address2: | SUITE 210 | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934544802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8059283678 | ||||||||
FaxNumber: | 8059286408 | ||||||||
Practice Location | |||||||||
Address1: | 1418 E MAIN ST | ||||||||
Address2: | SUITE 210 | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934544802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8059283678 | ||||||||
FaxNumber: | 8059286408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 01/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EBNER | ||||||||
AuthorizedOfficialFirstName: | GERALD | ||||||||
AuthorizedOfficialMiddleName: | DAVID | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
AuthorizedOfficialTelephone: | 8059283678 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | W10404D | 01 | CA | MEDICARE GROUP NUMBER | OTHER | DA4332 | 01 |   | MEICARE RR | OTHER |