1174783989 NPI number — BIG BEAR LAKE MEDICAL GROUP INC

Table of content: DR. JEFFREY JOHN SABIN M.D. (NPI 1356338644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174783989 NPI number — BIG BEAR LAKE MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIG BEAR LAKE 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:
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:
1174783989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41930 GARSTIN DR PO BOX 2915
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIG BEAR LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-866-6567
Provider Business Mailing Address Fax Number:
909-866-7030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41930 GARSTIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIG BEAR LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-866-6567
Provider Business Practice Location Address Fax Number:
909-866-7030
Provider Enumeration Date:
06/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NORMAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
909-866-6567

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  20A6319 , 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: 00AX63190 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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