Basic Information
| Provider Information | |||||||||
| NPI: | 1710305149 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS MEDICAL CENTER OF MODESTO, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DMC PROFESSIONAL BILLING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095781211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1441 FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095781211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERRY | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2095763790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.