1720035561 NPI number — GRASS VALLEY HEMATOLOGY/ONCOLOGY MED GRP

Table of content: (NPI 1720035561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720035561 NPI number — GRASS VALLEY HEMATOLOGY/ONCOLOGY MED GRP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRASS VALLEY HEMATOLOGY/ONCOLOGY MED GRP
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:
1720035561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRASS VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95945-1549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-274-6677
Provider Business Mailing Address Fax Number:
530-274-6678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 GLASSON WAY
Provider Second Line Business Practice Location Address:
SUITE L10
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-5723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-274-6677
Provider Business Practice Location Address Fax Number:
530-274-6678
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPBELL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
LAWRENCE
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
530-274-6677

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00340104 . This is a "RAILROAD MEDICARE PTAN - DAVID L CAMPBELL, MD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518959188 . This is a "INDIVIDUAL MD NPI# WILLIAM A NEWSOM JR" identifier . This identifiers is of the category "OTHER".
  • Identifier: DF1247 . This is a "RAILROAD MEDICARE PTAN FOR COMPANY CURRENT AS OF 08/2010" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1750373239 . This is a "INDIVIDUAL MD NPI# - DAVID CAMPBELL" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0061600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00314945 . This is a "RAILROAD MEDICARE PTAN - WILLIAM A NEWSON, JR, MD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ70159Z . This is a "PREVIOUS MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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