1588072698 NPI number — NEWSTART MEDICAL GROUP INC

Table of content: (NPI 1588072698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588072698 NPI number — NEWSTART MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEWSTART 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:
6
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:
1588072698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 486
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEIMAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95736-0486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-296-4417
Provider Business Mailing Address Fax Number:
877-425-5508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20601 WEST PAOLI LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEIMAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95736-0486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-296-4417
Provider Business Practice Location Address Fax Number:
877-425-5508
Provider Enumeration Date:
08/01/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GALLANT
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
252-619-8911

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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