Provider Demographics
NPI:1316023013
Name:INDEPENDENT PHYSICIAN MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:INDEPENDENT PHYSICIAN MEDICAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:K
Authorized Official - Last Name:COURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-550-5235
Mailing Address - Street 1:3340 TULLY RD
Mailing Address - Street 2:STE B-4
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0838
Mailing Address - Country:US
Mailing Address - Phone:209-550-5200
Mailing Address - Fax:209-338-5644
Practice Address - Street 1:3340 TULLY RD
Practice Address - Street 2:STE B-4
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0838
Practice Address - Country:US
Practice Address - Phone:209-550-5200
Practice Address - Fax:209-338-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41324261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48531Medicare UPIN