1730119926 NPI number — EOS MEDICAL GROUP PC

Table of content: (NPI 1730119926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730119926 NPI number — EOS MEDICAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EOS MEDICAL GROUP PC
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:
1730119926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTMINSTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92685-1090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-809-3573
Provider Business Mailing Address Fax Number:
562-468-0676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
666 STONELEIGH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-616-8100
Provider Business Practice Location Address Fax Number:
856-616-1919
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAMA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
845-226-8045

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02313642 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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