Basic Information
| Provider Information | |||||||||
| NPI: | 1073761805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JPS PHYSICIAN GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19801 ANITA AVE | ||||||||
| Address2: | |||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945464103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507436473 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1617 HEMPHILL ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178528440 | ||||||||
| FaxNumber: | 8179273603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | CORBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8179213431 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JPS PHYSICIAN GROUP INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.