1669575718 NPI number — PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669575718 NPI number — PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION
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:
PHILIP EBERSOLE M D FAMILY PRACTICE
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:
1669575718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30650 RANCHO CALIFORNIA RD STE D406-145
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92591-3215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-894-6868
Provider Business Mailing Address Fax Number:
951-894-6860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25405 HANCOCK AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92562-5982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-894-6868
Provider Business Practice Location Address Fax Number:
951-894-6860
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EBERSOLE
Authorized Official First Name:
EVA
Authorized Official Middle Name:
MARIA
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
951-894-6868

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C431720 , 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)





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