Basic Information
| Provider Information | |||||||||
| NPI: | 1578594206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN TALIEH MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 577134 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953577134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095220600 | ||||||||
| FaxNumber: | 2094910116 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 SPANOS CT | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095220600 | ||||||||
| FaxNumber: | 2094910116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TALIEH | ||||||||
| AuthorizedOfficialFirstName: | YAHYA | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2095220600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A73331 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00A733310 | 05 | CA | MEDICAID |