Basic Information
| Provider Information | |||||||||
| NPI: | 1821075748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL PROVIDERS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28900 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592284200 | ||||||||
| FaxNumber: | 5592243920 | ||||||||
| Practice Location | |||||||||
| Address1: | 1180 E SHAW AVE | ||||||||
| Address2: | STE 125 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937107812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592284200 | ||||||||
| FaxNumber: | 5592243920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | NAKAMURA | ||||||||
| AuthorizedOfficialFirstName: | GRANT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5592285400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G50552 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0068691 | 05 | CA | MEDICAID | GR0068696 | 05 | CA | MEDICAID | GR0068690 | 05 | CA | MEDICAID | GR0068695 | 05 | CA | MEDICAID | GR0068692 | 05 | CA | MEDICAID | GR0068693 | 05 | CA | MEDICAID | GR0068694 | 05 | CA | MEDICAID |