Provider Demographics
NPI:1215991583
Name:SOUTH VALLEY MULTI SPECIALTY MEDICAL GROUP INC
Entity type:Organization
Organization Name:SOUTH VALLEY MULTI SPECIALTY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:COSTANTINO
Authorized Official - Middle Name:T
Authorized Official - Last Name:GALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-293-1992
Mailing Address - Street 1:173 N MORRISON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2712
Mailing Address - Country:US
Mailing Address - Phone:408-293-1992
Mailing Address - Fax:408-293-6030
Practice Address - Street 1:173 N MORRISON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2712
Practice Address - Country:US
Practice Address - Phone:408-293-1992
Practice Address - Fax:408-293-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13665ZMedicare ID - Type Unspecified