Provider Demographics
NPI:1366550675
Name:CENTRAL COAST NEPHROLOGY MEDICAL CORPORATION
Entity type:Organization
Organization Name:CENTRAL COAST NEPHROLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:LOIS
Authorized Official - Last Name:REVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-755-7999
Mailing Address - Street 1:917 BLANCO CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-4446
Mailing Address - Country:US
Mailing Address - Phone:831-755-7999
Mailing Address - Fax:831-755-7975
Practice Address - Street 1:917 BLANCO CIRCLE
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-4446
Practice Address - Country:US
Practice Address - Phone:831-755-7999
Practice Address - Fax:831-755-7975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG308710207RN0300X
CAG507670207RN0300X
CAA66902207RN0300X
CAA767040207RN0300X
CAA116032207RN0300X
CAA36123207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A669020Medicaid
CA00A767040Medicaid
CA00G507670Medicaid
CA00G308710Medicaid
CA00A361230Medicaid
CAZZZ24103ZOtherMEDICARE PTAN ANNA MALKINA, MD
CAAC2224208OtherRAYMOND R CARRILLO MD DEA
CA00G308710Medicaid
CAAK9664207OtherGOPAL G KRISHNA MD DEA
CA00A361230Medicaid
CAZZZ24103ZOtherMEDICARE PTAN ANNA MALKINA, MD
CAC32540Medicare UPIN
CAAC2224208OtherRAYMOND R CARRILLO MD DEA
CAI30495Medicare UPIN
CAZZZ24103ZMedicare ID - Type UnspecifiedMICHAEL E DICUS MD
CABP7526001OtherDENNIS PHAN MD DEA
CAH69429Medicare UPIN
CAA44579Medicare UPIN
CAZZZ24103ZMedicare ID - Type UnspecifiedGOPAL G KRISHNA MD
CAZZZ24103ZMedicare ID - Type UnspecifiedBARBARA L REVER MD
CA00A669020Medicaid