1073590105 NPI number — PRIMARY CARE ASSOCIATES MEDICAL GROUP, INC

Table of content: (NPI 1073590105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073590105 NPI number — PRIMARY CARE ASSOCIATES MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY CARE ASSOCIATES 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:
1073590105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3998 VISTA WAY
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92056-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-724-5173
Provider Business Mailing Address Fax Number:
760-724-5265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3998 VISTA WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92056-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-724-5173
Provider Business Practice Location Address Fax Number:
760-724-5265
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRODY
Authorized Official First Name:
JEANNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
760-724-1033

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A70831 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: A47884 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X , with the licence number: A70831 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: A68137 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: E4564 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA17120 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0089840 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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