Provider Demographics
NPI:1538436274
Name:ST, JUDE HERITAGE MEDICAL GROUP
Entity type:Organization
Organization Name:ST, JUDE HERITAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:O'NEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-578-8616
Mailing Address - Street 1:731 S. HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:731 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-2753
Practice Address - Country:US
Practice Address - Phone:714-446-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21377363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty