1619922911 NPI number — PITTSBURG-ANTIOCH MEDICAL GROUP A PROFESSIONAL CORPORATION

Table of content: (NPI 1619922911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619922911 NPI number — PITTSBURG-ANTIOCH MEDICAL GROUP A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PITTSBURG-ANTIOCH MEDICAL GROUP A PROFESSIONAL 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:
SPRINGHILL MEDICAL GROUP
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:
1619922911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2220 GLADSTONE DR
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
PITTSBURG
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94565-5123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
924-432-3318
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2220 GLADSTONE DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94565-5123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
924-432-3318
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEL RIO
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
925-635-2978

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A50205 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RE0101X , with the licence number: A836250 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: G43569 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: A82612 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0053010 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A826120 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS2543 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G327970 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A651470 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A502050 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G435690 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A836250 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ34060Z . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com