Basic Information
Provider Information | |||||||||
NPI: | 1962551861 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOHN MUIR TRAUMA PHYSICIANS BILLING SERVICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 TREAT BLVD | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945972142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259475331 | ||||||||
FaxNumber: | 9259412177 | ||||||||
Practice Location | |||||||||
Address1: | 1601 YGNACIO VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945983122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259475331 | ||||||||
FaxNumber: | 9259412177 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2007 | ||||||||
LastUpdateDate: | 10/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOODY | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINACIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9259252159 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |   | 207L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207P00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207RC0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207XX0801X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207Y00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   | 2081P0004X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Spinal Cord Injury Medicine | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2085R0202X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2086S0122X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208800000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   | 2086S0127X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
ID | Type | State | Issuer | Description | GR002814J | 05 | CA |   | MEDICAID | GR0028145 | 05 | CA |   | MEDICAID | GR0028148 | 05 | CA |   | MEDICAID | GR0028149 | 05 | CA |   | MEDICAID | GR002814K | 05 | CA |   | MEDICAID | GR002814G | 05 | CA |   | MEDICAID | GR0028142 | 05 | CA |   | MEDICAID | GR0028144 | 05 | CA |   | MEDICAID | GR0028143 | 05 | CA |   | MEDICAID | GR002814H | 05 | CA |   | MEDICAID | GR002814A | 05 | CA |   | MEDICAID |