1568522878 NPI number — PREMIER URGENT CARE A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1568522878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568522878 NPI number — PREMIER URGENT CARE A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER URGENT CARE A PROFESSIONAL MEDICAL CORPORATION
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:
TRACY OCCUPATIONAL MEDICAL CENTER
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:
1568522878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
644 W 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95376-3437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-832-8984
Provider Business Mailing Address Fax Number:
209-832-8988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
644 W 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95376-3437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-832-8984
Provider Business Practice Location Address Fax Number:
209-832-8988
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
JAGDISH
Authorized Official Middle Name:
AMBALAL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-832-8984

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A31816 , 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: A855092 , 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: 20A7496 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QS0010X , with the licence number: 20A7496 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 20A7496 . This is a "STATE LICENSE DR. PULLIAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BH8637881 . This is a "DR. HUBLI BNDD NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A31816 . This is a "STATE LICENSE DR. PATEL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A85126 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: BP4399944 . This is a "DR. PULLIAM BNDD NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A855092 . This is a "STATE LICENSE DR. HUBLI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: AP8331112 . This is a "DR. PATEL BNDD NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A318160 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05D0695064903593 . This is a "CLIA NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: AP8331112 . This is a "BNDD NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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