1871641571 NPI number — MID COUNTY SURGICAL MEDICAL GROUP, INC.

Table of content: MR. CRISTIAN STEVEN DUENEZ CADCR (NPI 1629893391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871641571 NPI number — MID COUNTY SURGICAL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID COUNTY SURGICAL 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:
1871641571
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
603 CAPITOLA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPITOLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95010-2751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-476-5403
Provider Business Mailing Address Fax Number:
831-476-4107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
603 CAPITOLA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPITOLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95010-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-476-5403
Provider Business Practice Location Address Fax Number:
831-476-4107
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANANE-SEFAH
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
CAMARA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
831-476-5403

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  G23854 , 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)

  • Identifier: GR0030290 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G23854 . This is a "MD JOHN C. ANANE-SEFAH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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