Basic Information
| Provider Information | |||||||||
| NPI: | 1619168952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN JOAQUIN VALLEY NEONATAL MEDICAL ASSOCATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 MCHENRY AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095718330 | ||||||||
| FaxNumber: | 2094917184 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCH CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952319693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095718330 | ||||||||
| FaxNumber: | 2094917184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING AGENT | ||||||||
| AuthorizedOfficialTelephone: | 2095718330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 50579 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0071220 | 05 | CA | MEDICAID | 50579 | 01 | CA | BLUE SHIELD | OTHER |