Basic Information
| Provider Information | |||||||||
| NPI: | 1912054586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEO-PEDS MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1359 | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926741359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494923514 | ||||||||
| FaxNumber: | 9493662390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1798 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098659500 | ||||||||
| FaxNumber: | 9493662390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | NORDBERG | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCOUNTS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9494923514 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0100400 | 05 | CA | MEDICAID |