1174675417 NPI number — WASHINGTON TOWNSHIP MEDICAL GROUP

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 1174675417 NPI number — WASHINGTON TOWNSHIP MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHINGTON TOWNSHIP 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:
WASHINGTON TOWNSHIP MEDICAL GROUP, INC
Provider Other Organization Name Type Code:
5
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:
1174675417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39141 CIVIC CENTER DR
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94538-5818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-248-1000
Provider Business Mailing Address Fax Number:
510-608-6055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38690 STIVERS ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94536-5279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-248-1040
Provider Business Practice Location Address Fax Number:
510-797-7426
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
510-248-1000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G36600 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Y00000X , with the licence number: G36600 , 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: GR0104740 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ69534Z . This is a "BLUE SHIELD 2ND LOCATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ69533Z . This is a "BLUE SHIELD GRP PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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