Basic Information
| Provider Information | |||||||||
| NPI: | 1508182833 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF SAN LUIS OBISPO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535700 | ||||||||
| FaxNumber: | 5593535708 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 MURRAY AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934051806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055467766 | ||||||||
| FaxNumber: | 8055467932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | KAJI | ||||||||
| AuthorizedOfficialFirstName: | DEVONNA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5593535700 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA, INC. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1013968296 | 01 | CA | GROUP NPI | OTHER | ZZZ13884Z | 01 | CA | MEDICARE GROUP | OTHER | GR0078680 | 05 | CA | MEDICAID |