Basic Information
| Provider Information | |||||||||
| NPI: | 1962439463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC HEART AND VASCULAR MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 E MARCH LN | ||||||||
| Address2: | SUITE D400 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952106629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094643615 | ||||||||
| FaxNumber: | 2094641311 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 S HIGHWAY 26 | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | VALLEY SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952528422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778357938 | ||||||||
| FaxNumber: | 2094641311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | POWELL | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2094643615 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | FNP33233 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | GR0086060 | 05 | CA | MEDICAID | ZZZ59842Z | 01 | CA | BC BS | OTHER |