1467709220 NPI number — MARY GESSNER-PETERSON MEDICAL GROUP, INC

Table of content: (NPI 1467709220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467709220 NPI number — MARY GESSNER-PETERSON MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY GESSNER-PETERSON 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:
CALIFORNIA MOBILE PHYSICIANS AND COMPREHENSIVE MEDICINE
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:
1467709220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2710 ALPINE BLVD
Provider Second Line Business Mailing Address:
SUITE 434
Provider Business Mailing Address City Name:
ALPINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91901-2276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-326-4445
Provider Business Mailing Address Fax Number:
619-326-4445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1730 ALPINE BLVD STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91901-3878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-326-4445
Provider Business Practice Location Address Fax Number:
619-722-1721
Provider Enumeration Date:
08/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GESSNER-PETERSON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-778-5011

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  20A11744 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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