Basic Information
| Provider Information | |||||||||
| NPI: | 1447288345 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEAM PHYSICIANS OF CALIFORNIA MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634600 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452634600 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 GARCES HWY | ||||||||
| Address2: | |||||||||
| City: | DELANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932153690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259241600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 9252516901 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | DD4942 | 01 | CA | TULARE RAILROAD | OTHER | ZZZ65040Z | 01 | CA | TULARE BLUE SHIELD | OTHER | CG0978 | 01 | CA | LA COMMUNITY RAILROAD | OTHER | ZZZ03631Z | 01 | CA | DELANO BLUE SHIELD | OTHER | DD4942 | 01 | CA | DELANO RAILROAD | OTHER | GR0083247 | 05 | CA | MEDICAID | ZZZ002402 | 01 | CA | LA COMMUNITY BLUE SHIELD | OTHER | GR008324G | 05 | CA | MEDICAID | GR0083246 | 05 | CA | MEDICAID | GR008324E | 05 | CA | MEDICAID | GR008324H | 05 | CA | MEDICAID |