Basic Information
| Provider Information | |||||||||
| NPI: | 1649562315 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARSHALL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARSHALL ORTHOPEDICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45680 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941450680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306262787 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4300 GOLDEN CENTER DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956676278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306262787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELDRIDGE | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5306262770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.