1891131298 NPI number — FIRST PEDIATRICS MEDICAL GROUP, INC.

Table of content: (NPI 1891131298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891131298 NPI number — FIRST PEDIATRICS MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST PEDIATRICS MEDICAL GROUP, INC.
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:
1891131298
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6255 N FRESNO ST
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93710-5271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-435-1500
Provider Business Mailing Address Fax Number:
559-478-5082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6255 N FRESNO ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93710-5271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-435-1500
Provider Business Practice Location Address Fax Number:
559-478-5082
Provider Enumeration Date:
05/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MANIAM-MOHAN
Authorized Official First Name:
MYDILI
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
559-435-1500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  C54039 , 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: C54039 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: C54717 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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