Basic Information
| Provider Information | |||||||||
| NPI: | 1912987553 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | UC DAVIS MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 BROADWAY STE 1200 | ||||||||
| Address2: | STE 1200 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167349255 | ||||||||
| FaxNumber: | 9164518494 | ||||||||
| Practice Location | |||||||||
| Address1: | 2660 W COVELL BLVD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956165645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307473000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | SLAPNIK | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9167348203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | GR0063734 | 05 | CA | MEDICAID |