Provider Demographics
NPI:1396147419
Name:AAA FAMILY MEDICAL GROUP
Entity type:Organization
Organization Name:AAA FAMILY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MONTANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:862-252-0531
Mailing Address - Street 1:15995 TUSCOLA RD STE 202
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-242-5111
Mailing Address - Fax:760-418-6486
Practice Address - Street 1:15995 TUSCOLA RD STE 202
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-5111
Practice Address - Fax:760-418-6486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEJ644VMedicare UPIN