1568852473 NPI number — UCR HEALTH PSYCHIATRY - BROCKTON

Table of content: DR. RYAN SCOTT WILSON M.D. (NPI 1619315629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568852473 NPI number — UCR HEALTH PSYCHIATRY - BROCKTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UCR HEALTH PSYCHIATRY - BROCKTON
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:
1568852473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-2130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-2130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-412-1973
Provider Business Mailing Address Fax Number:
213-412-1981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5887 BROCKTON AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92506-1853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-827-7961
Provider Business Practice Location Address Fax Number:
951-530-4783
Provider Enumeration Date:
01/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HEYDT
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
714-456-2986

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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