1013515287 NPI number — BALWIN PARK MEDICAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013515287 NPI number — BALWIN PARK MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALWIN PARK MEDICAL GROUP, INC.
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:
6
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:
1013515287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14652 PACIFIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWIN PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91706-5333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-337-1360
Provider Business Mailing Address Fax Number:
626-962-1375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14652 PACIFIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALDWIN PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91706-5333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-337-1360
Provider Business Practice Location Address Fax Number:
323-962-1375
Provider Enumeration Date:
10/11/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DE SILVA
Authorized Official First Name:
ERRAJITH
Authorized Official Middle Name:
BERTRAND R
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
714-673-2603

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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