1962455477 NPI number — FREMONT RIDEOUT MEDICAL GROUP INC

Table of content: (NPI 1962455477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962455477 NPI number — FREMONT RIDEOUT MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREMONT RIDEOUT 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:
6
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:
1962455477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7096
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95267-0096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-956-7725
Provider Business Mailing Address Fax Number:
209-956-7733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 DEL NORTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUBA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-751-4800
Provider Business Practice Location Address Fax Number:
530-751-4884
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SERAFIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
GROUP PRESIDENT
Authorized Official Telephone Number:
530-751-4800

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ04808Z . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0092252 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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