1619090610 NPI number — CROWN CITY MEDICAL GROUP INC.

Table of content: DR. PRIYA MARY JACOB MD (NPI 1831766542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619090610 NPI number — CROWN CITY MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROWN CITY 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:
1619090610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3208 SANTA ANITA AVE
Provider Second Line Business Mailing Address:
# 200
Provider Business Mailing Address City Name:
EL MONTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91733-1360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-454-1990
Provider Business Mailing Address Fax Number:
626-454-1995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3208 SANTA ANITA AVE
Provider Second Line Business Practice Location Address:
# 200
Provider Business Practice Location Address City Name:
EL MONTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91733-1360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-454-1990
Provider Business Practice Location Address Fax Number:
626-454-1995
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TYSON
Authorized Official First Name:
MAUREEN
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
626-798-8792

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0041812 . This is a "MEDI-CAL PROVIDER #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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