Provider Demographics
NPI:1063927770
Name:HUMBOLDT PEDIATRIC MEDICAL CORPORATION, INC.
Entity type:Organization
Organization Name:HUMBOLDT PEDIATRIC MEDICAL CORPORATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:BERTRAM
Authorized Official - Last Name:POYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-599-0642
Mailing Address - Street 1:1011 FRESHWATER RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-9457
Mailing Address - Country:US
Mailing Address - Phone:707-599-0642
Mailing Address - Fax:
Practice Address - Street 1:2192 CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3610
Practice Address - Country:US
Practice Address - Phone:707-839-1000
Practice Address - Fax:707-839-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64795208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548234693Medicaid
CA1629074570Medicaid