Provider Demographics
NPI:1588850952
Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC. - DEPT. OF CARDIOLOGY
Entity type:Organization
Organization Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC. - DEPT. OF CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5700
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:MAILSTOP FC14
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-6257
Mailing Address - Fax:559-353-5455
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:MAILSTOP FC14
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-6257
Practice Address - Fax:559-353-5455
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078686Medicaid
CAGR0078686Medicaid