1326384512 NPI number — IDENTITY MEDICAL GROUP, INC.

Table of content: MS. PAIGE F. PATTERSON NP (NPI 1154507945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326384512 NPI number — IDENTITY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDENTITY 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:
1326384512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
751 E DAILY DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93010-6076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-256-7810
Provider Business Mailing Address Fax Number:
805-256-7840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 E DAILY DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-6076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-256-7810
Provider Business Practice Location Address Fax Number:
805-256-7840
Provider Enumeration Date:
12/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DEUTSCH,
Authorized Official First Name:
GARY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
GENERAL PARTNER
Authorized Official Telephone Number:
805-256-7810

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , 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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