1497702724 NPI number — CADUCEUS PHYSICIANS MEDICAL GROUP

Table of content: KELSEY SHAKE MCCALLUM SLP (NPI 1285250027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497702724 NPI number — CADUCEUS PHYSICIANS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CADUCEUS PHYSICIANS MEDICAL GROUP
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:
1497702724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18200 YORBA LINDA BLVD STE 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORBA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92886-4043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-646-8000
Provider Business Mailing Address Fax Number:
714-572-2562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18200 YORBA LINDA BLVD STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORBA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92886-4044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-646-8000
Provider Business Practice Location Address Fax Number:
714-572-2562
Provider Enumeration Date:
05/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DENICOLA
Authorized Official First Name:
GREGG
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
714-646-8000

Provider Taxonomy Codes

  • Taxonomy code: 133N00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 247100000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , 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: 05D0938185 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ58296Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0084863 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".