1457439572 NPI number — MERIDIAN MEDICAL GROUP PROFESSIONAL CORP

Table of content: (NPI 1457439572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457439572 NPI number — MERIDIAN MEDICAL GROUP PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN MEDICAL GROUP PROFESSIONAL CORP
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:
1457439572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1047 E CAPITOL EXPY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95121-2415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-754-8988
Provider Business Mailing Address Fax Number:
408-754-8289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1047 E CAPITOL EXPY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95121-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-754-8988
Provider Business Practice Location Address Fax Number:
408-754-8289
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
408-754-8988

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  A303360 , 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: 880357380 . This is a "TAX ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0070181 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0070182 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A303360 . This is a "MEDICAL LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1134228752 . This is a "NPI NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ41448Z . This is a "BLUE SHIELD NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0070180 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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