1386890044 NPI number — GREGORY K. SUELZLE, M.D., A MEDICAL CORPORATION

Table of content: (NPI 1386890044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386890044 NPI number — GREGORY K. SUELZLE, M.D., A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREGORY K. SUELZLE, M.D., A MEDICAL CORPORATION
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 GROVE MEDICAL GROUP
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:
1386890044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1330 SAN BERNARDINO RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91786-4928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-981-0608
Provider Business Mailing Address Fax Number:
866-695-1267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 SAN BERNARDINO RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786-4928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-981-0608
Provider Business Practice Location Address Fax Number:
866-695-1267
Provider Enumeration Date:
08/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SUELZLE
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-981-0608

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G78385 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: G77184 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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