Basic Information
| Provider Information | |||||||||
| NPI: | 1649208463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC HEART AND VASCULAR MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 E MARCH LANE | ||||||||
| Address2: | SUITE D400 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952105667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094643615 | ||||||||
| FaxNumber: | 2094641311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 E MARCH LANE | ||||||||
| Address2: | SUITE D400 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952105667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094643615 | ||||||||
| FaxNumber: | 2094641311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOHNA | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2094643615 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | FNP33233 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 060057321 | 01 | CA | RAILROAD MEDICARE GROUP # | OTHER | ZZZ59840Z | 01 | CA | BC/BS GROUP PROVIDER # | OTHER | GR0086062 | 05 | CA | MEDICAID |