1114947058 NPI number — CHOICE PROVIDERS MEDICAL GROUP INC

Table of content: (NPI 1114947058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114947058 NPI number — CHOICE PROVIDERS MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE PROVIDERS 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:
NOBLE COMMUNITY MEDICAL ASSOCAITES
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:
1114947058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17750 SHERMAN WAY
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
RESEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91335-3380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-705-7200
Provider Business Mailing Address Fax Number:
818-343-0805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17750 SHERMAN WAY
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
RESEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91335-3380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-705-7200
Provider Business Practice Location Address Fax Number:
818-343-0805
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALEK
Authorized Official First Name:
HANY
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
818-705-7200

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC21916 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DC28504 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DC20140 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DC20098 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 173F00000X , with the licence number: 173F00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A36588 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: A35585 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: A64420 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: A44927 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: C30241 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: C31379 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A25062 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A54207 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: G78404 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA13428 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZZZ50145Z . This is a "BLUE SHEILD (RESEDA)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ50147Z . This is a "BLUE SHEILD (INGLEWOOD)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ50174Z . This is a "BLUE SHEILD (S.B.)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ50176Z . This is a "BLUE SHEILD (C.P)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ501722Z . This is a "BLUE SHEILD (G.H.)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ50172Z . This is a "BLUE SHEILD (EL MONTE)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ50173Z . This is a "BLUE SHEILD (PASADENA)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0102431 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0102433 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ50146Z . This is a "BLUE SHEILD (L.A.)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0102434 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ501752 . This is a "BLUE SHEILD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0102430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0102432 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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