Basic Information
| Provider Information | |||||||||
| NPI: | 1104178615 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PULMONARY MEDICINE ASSOCIATES MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 CADILLAC DRIVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164827623 | ||||||||
| FaxNumber: | 9164887432 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 CADILLAC DRIVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164827623 | ||||||||
| FaxNumber: | 9164887432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 10/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | EFSTRATIS | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANGER | ||||||||
| AuthorizedOfficialTelephone: | 9164827623 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 22046 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 1407880719 | 01 | CA | PRACTICE NPI NUMBER | OTHER |