1861697328 NPI number — J. TALISMAN POMEROY, IV, M.D.

Table of content: (NPI 1861697328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861697328 NPI number — J. TALISMAN POMEROY, IV, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. TALISMAN POMEROY, IV, M.D.
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:
J. TALISMAN POMEROY, IV, M.D.
Provider Other Organization Name Type Code:
4
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:
1861697328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3035 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOQUEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95073-2204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-462-8750
Provider Business Mailing Address Fax Number:
831-475-5713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3035 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOQUEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95073-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-462-8750
Provider Business Practice Location Address Fax Number:
831-475-5713
Provider Enumeration Date:
06/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TASHIRO
Authorized Official First Name:
MARLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL BILLER
Authorized Official Telephone Number:
831-462-8755

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G414340 , 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: 1861697328 . This is a "GROUP NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G414341 . This is a "MEDICARE INDIVIDUAL PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G414340 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396885034 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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