Basic Information
| Provider Information | |||||||||
| NPI: | 1649509647 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC GASTROENTEROLOGY CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1895 E CASTLEBROOK DR | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937303456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535745 | ||||||||
| FaxNumber: | 5593536033 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535745 | ||||||||
| FaxNumber: | 5593536033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2009 | ||||||||
| LastUpdateDate: | 12/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | JAMI | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
| AuthorizedOfficialMiddleName: | MUSLIM | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5593535745 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | C050493 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CA | MEDICAID |