Basic Information
| Provider Information | |||||||||
| NPI: | 1720471097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERCEDE HEALTH OF CALIFORNIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 CRAWFORD ST | ||||||||
| Address2: | SUITE 1350 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770029000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324763900 | ||||||||
| FaxNumber: | 8324766494 | ||||||||
| Practice Location | |||||||||
| Address1: | 1680 E 120TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900593026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324763900 | ||||||||
| FaxNumber: | 8324766494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | MATHEWS | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8324763900 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTERCEDE HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080840401 | 05 | TX | MEDICAID | 006694600 | 05 | FL | MEDICAID |