1376569657 NPI number — WALLACE G GOSNEY MD & GILBERT R TURNER MD PTRS

Table of content: (NPI 1376569657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376569657 NPI number — WALLACE G GOSNEY MD & GILBERT R TURNER MD PTRS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLACE G GOSNEY MD & GILBERT R TURNER MD PTRS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UPLAND SURGICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376569657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 N 13TH AVE STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91786-4965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-920-0525
Provider Business Mailing Address Fax Number:
909-920-0526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 N 13TH AVE STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786-4965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-920-0525
Provider Business Practice Location Address Fax Number:
909-920-0526
Provider Enumeration Date:
07/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SPIVACK
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
909-946-5320

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  G67360 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: A65402 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: A65402 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X , with the licence number: G67360 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0071670 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".