1285637637 NPI number — GM SALLY MELLGREN, M.D. INC.

Table of content: (NPI 1285637637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285637637 NPI number — GM SALLY MELLGREN, M.D. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GM SALLY MELLGREN, M.D. 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:
1285637637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 VISTA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92056-4522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-757-1144
Provider Business Mailing Address Fax Number:
760-721-7701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3621 VISTA WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92056-4522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-757-1144
Provider Business Practice Location Address Fax Number:
760-721-7701
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROPER
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
760-757-1144

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  G53485 , 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: 00G534850 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33-0241763A . This is a "HEALTHNET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ07175Z . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com