1568474096 NPI number — PATTERSON AND TEDFORD PEDIATRICS, A CALIFORNIA MEDICAL CORP

Table of content: (NPI 1568474096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568474096 NPI number — PATTERSON AND TEDFORD PEDIATRICS, A CALIFORNIA MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATTERSON AND TEDFORD PEDIATRICS, A CALIFORNIA MEDICAL CORP
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:
Provider Other Organization Name Type Code:
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:
1568474096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7700 MORRO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATASCADERO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93422-4435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-466-6622
Provider Business Mailing Address Fax Number:
805-461-0361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 MORRO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATASCADERO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93422-4435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-466-6622
Provider Business Practice Location Address Fax Number:
805-461-0361
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
CASSIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
805-466-6622

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  C2202292 , 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)

  • Identifier: 357801011 . This is a "CIGNA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4315040 . This is a "AETNA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0089110 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ01321Z . This is a "BLUE SHIELD OF CA GRP PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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