Basic Information
| Provider Information | |||||||||
| NPI: | 1851586523 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS NETWORK SERVICES MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 377 E CHAPMAN AVE STE 240 | ||||||||
| Address2: | |||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928705091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145722039 | ||||||||
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| Practice Location | |||||||||
| Address1: | 377 E CHAPMAN AVE STE 240 | ||||||||
| Address2: | |||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928705091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145722039 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | TABB | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7145722039 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | CJ8168 | 01 | CA | RAILROAD MEDICARE | OTHER | GSD003040 | 05 | CA | MEDICAID |