Basic Information
| Provider Information | |||||||||
| NPI: | 1922260629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL VALLEY NEONATAL MEDICAL GRP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 MCHENRY AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095718330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 W ACACIA ST | ||||||||
| Address2: | NEONATAL DEPARTMENT | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952032405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095718330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | SIMKO | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2095718330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.