1073853636 NPI number — CHESTNUT MEDICAL GROUP OF FRESNO

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 1073853636 NPI number — CHESTNUT MEDICAL GROUP OF FRESNO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESTNUT MEDICAL GROUP OF FRESNO
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:
1073853636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1348 W HERNDON AVENUE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93711-7181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-573-7260
Provider Business Mailing Address Fax Number:
559-573-7254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1348 W HERNDON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93711-7181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-573-7260
Provider Business Practice Location Address Fax Number:
559-573-7254
Provider Enumeration Date:
02/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RAO
Authorized Official First Name:
UMA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
559-573-7260

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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