1558354373 NPI number — PELLEGRIN BROAD MORSE & MOY MDS & DO

Table of content: (NPI 1558354373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558354373 NPI number — PELLEGRIN BROAD MORSE & MOY MDS & DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PELLEGRIN BROAD MORSE & MOY MDS & DO
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:
1558354373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
143 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS GATOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95030-6903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-354-3920
Provider Business Mailing Address Fax Number:
408-354-0782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
143 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS GATOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95030-6903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-354-3920
Provider Business Practice Location Address Fax Number:
408-354-0782
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HANSON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE/FINANCIAL MANAGER
Authorized Official Telephone Number:
408-354-4030

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X , with the licence number:  G41377 G75242 A55016 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: G41377 G67157 G75242 , 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: CJ4068 . This is a "RR MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: FNP22360 . This is a "FICT NAME PERMIT" identifier . This identifiers is of the category "OTHER".




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