1235286907 NPI number — NATIONWIDE MEDICAL GROUP, INC

Table of content: (NPI 1235286907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235286907 NPI number — NATIONWIDE MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATIONWIDE 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:
AEGIS MEDICAL SYSTEMS, INC.
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:
1235286907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7246 REMMET AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANOGA PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91303-1531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-206-0360
Provider Business Mailing Address Fax Number:
818-206-0383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11776 MARIPOSA RD
Provider Second Line Business Practice Location Address:
SUITE #103
Provider Business Practice Location Address City Name:
HESPERIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92345-1622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-956-2462
Provider Business Practice Location Address Fax Number:
760-956-7542
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GIRGIS
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL DIRECTOR
Authorized Official Telephone Number:
661-861-9967

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X , with the licence number: 14837 , 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: GR008716M , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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