Basic Information
Provider Information | |||||||||
NPI: | 1972983815 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAZ ALLERGY, ASTHMA & SINUS CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7471 N FRESNO ST | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937202457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5594364500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1415 BADGER FLAT RD | ||||||||
Address2: | A | ||||||||
City: | LOS BANOS | ||||||||
State: | CA | ||||||||
PostalCode: | 936358600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2097108684 | ||||||||
FaxNumber: | 2097108763 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2015 | ||||||||
LastUpdateDate: | 06/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAZ | ||||||||
AuthorizedOfficialFirstName: | MALIK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO/VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5594364500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
ID | Type | State | Issuer | Description | GR0043790 | 05 | CA |   | MEDICAID | ZZZ21572Z | 01 | CA | GRP MCARE PTAN FOR BAZ ALLERGY, ASTHMA & SINUS CENTER | OTHER |