Basic Information
| Provider Information | |||||||||
| NPI: | 1609832252 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILLSIDE OBSTETRICS & GYNECOLGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 GUZZI LN | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363750 | ||||||||
| FaxNumber: | 2095329811 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 GUZZI LN | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363750 | ||||||||
| FaxNumber: | 2095329811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 09/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | TEEL | ||||||||
| AuthorizedOfficialFirstName: | DONOVAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2095363750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G30879 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00G308790 | 05 | CA | MEDICAID |