1528011764 NPI number — VERICARE OF CALIFORNIA MEDICAL GROUP

Table of content: (NPI 1528011764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528011764 NPI number — VERICARE OF CALIFORNIA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERICARE OF CALIFORNIA MEDICAL GROUP
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:
VERICARE
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:
1528011764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/11/2007
NPI Reactivation Date:
08/09/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4715 VIEWRIDGE AVE
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-1680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-257-8715
Provider Business Mailing Address Fax Number:
800-816-1655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
81 PROFESSIONAL CTR PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN RAFAEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94903-2797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-257-8715
Provider Business Practice Location Address Fax Number:
800-819-1655
Provider Enumeration Date:
05/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BUDD
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
ASSISTANT CORPORATE SECRETARY
Authorized Official Telephone Number:
800-257-8715

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CC7816 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GPS000150 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".