Provider Demographics
NPI:1194915157
Name:PSF GASTRO
Entity type:Organization
Organization Name:PSF GASTRO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FARACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-516-4295
Mailing Address - Street 1:455 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3835
Mailing Address - Country:US
Mailing Address - Phone:714-516-4295
Mailing Address - Fax:714-289-4798
Practice Address - Street 1:455 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3835
Practice Address - Country:US
Practice Address - Phone:714-516-4295
Practice Address - Fax:714-289-4798
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC SUBSPECIALTY FACULTY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-26
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090406Medicaid
CAGR0090404Medicaid
CAGR0090409Medicaid
CAGR0090407Medicaid
CAGR0090405Medicaid
CAGR009040AMedicaid
CA1790850279OtherNPI
CAGR0090395Medicaid