Basic Information
| Provider Information | |||||||||
| NPI: | 1699703728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROLOGICAL CONSULTANTS MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 L ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164546850 | ||||||||
| FaxNumber: | 9164546852 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 L ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164546850 | ||||||||
| FaxNumber: | 9164546852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | AU | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9164546850 | ||||||||
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| 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 | G32757 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ72178Z | 01 | CA | MEDICARE GROUP NUMBER | OTHER |