Basic Information
| Provider Information | |||||||||
| NPI: | 1558397141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN MUIR PERINATAL MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9017 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945980917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259417985 | ||||||||
| FaxNumber: | 9259522850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1656 N. CALFIORNIA BLVD. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259417955 | ||||||||
| FaxNumber: | 9259417986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 12/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | SORENSON | ||||||||
| AuthorizedOfficialFirstName: | M. | ||||||||
| AuthorizedOfficialMiddleName: | KATHERINE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9259522888 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOHN MUIR PHYSICIAN NETWORK | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR006875K | 05 | CA | MEDICAID |