Basic Information
| Provider Information | |||||||||
| NPI: | 1457603573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 2823 FRESNO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | HIGH | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN SERVICES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5594432682 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.