Basic Information
Provider Information | |||||||||
NPI: | 1457400293 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOHN MUIR TRAUMA PHYSICIAN BILLING SERVICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9021 | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945980921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259475331 | ||||||||
FaxNumber: | 9259412177 | ||||||||
Practice Location | |||||||||
Address1: | 1601 YGNACIO VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945983122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259475331 | ||||||||
FaxNumber: | 9259412177 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2007 | ||||||||
LastUpdateDate: | 07/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOODY | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9259393000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207T00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | GR002814A | 05 | CA |   | MEDICAID |