Basic Information
| Provider Information | |||||||||
| NPI: | 1962833319 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRST CHOICE PHYSICIAN PARTNERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREATER MODESTO MEDICAL SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1079 EUCALYPTUS ST | ||||||||
| Address2: | SUITE #A | ||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953374317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092396008 | ||||||||
| FaxNumber: | 2092393408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1079 EUCALYPTUS ST | ||||||||
| Address2: | SUITE #A | ||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953374317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092396008 | ||||||||
| FaxNumber: | 2092393408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2013 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | KOUREY | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7144286842 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIRST CHOICE PHYSICIAN PARTNERS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.