Basic Information
| Provider Information | |||||||||
| NPI: | 1548252703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAL | ||||||||
| FirstName: | JAGDEEP | ||||||||
| MiddleName: | SINGH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1896 ROLLING ROCK CT | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959931425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307014037 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3001 DOUGLAS BLVD # 325 | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307014037 | ||||||||
| FaxNumber: | 9162419845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 03/23/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A84035 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DL880Y | 01 | CA | MEDICARE PTAN - YUBA SUTTER HOSPITALIST GROUP | OTHER | 00A840350 | 01 | CA | BLUE SHIELD PIN # | OTHER | 1548252703 | 05 | CA | MEDICAID | DL880Z | 01 | CA | MEDICARE PTAN - AMPLA HEALTH AT OROVILLE FAMILY HEALTH CENTER | OTHER |