Provider Demographics
NPI:1063691467
Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC. - DEPT OF NEUROLOGY
Entity type:Organization
Organization Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC. - DEPT OF NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5700
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:MB20
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-6215
Mailing Address - Fax:559-353-6222
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:MB20
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-6215
Practice Address - Fax:559-353-6222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-01
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078689Medicaid
CA1013968296OtherSMG GENERAL GROUP NPI
CAZZZ13884ZMedicare PIN