Basic Information
| Provider Information | |||||||||
| NPI: | 1578643490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA ONCOLOGY MEDICAL GROUP OF TURLOCK, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6121 N THESTA ST | ||||||||
| Address2: | 204 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937108603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594387390 | ||||||||
| FaxNumber: | 5594387166 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 E TUOLUMNE RD | ||||||||
| Address2: | 103 | ||||||||
| City: | TURLOCK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953821548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096698300 | ||||||||
| FaxNumber: | 2096699300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | ELDALY | ||||||||
| AuthorizedOfficialFirstName: | MOHAMED | ||||||||
| AuthorizedOfficialMiddleName: | ELSAYED | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2096698300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | J13239 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | GR0103970 | 05 | CA | MEDICAID | ZZZ67013Z | 01 | CA | BLUE SHIELD | OTHER |