Provider Demographics
NPI:1699758565
Name:VENTANA HEALTH AND MEDICAL CENTER
Entity type:Organization
Organization Name:VENTANA HEALTH AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-489-2205
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-1410
Mailing Address - Country:US
Mailing Address - Phone:805-489-2205
Mailing Address - Fax:805-489-2206
Practice Address - Street 1:901 OAK PARK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3216
Practice Address - Country:US
Practice Address - Phone:805-489-2205
Practice Address - Fax:805-489-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2537515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07475ZOtherBLUE SHIELD OF CALIFORNIA
CADA8203Medicare PIN
CABH6442Medicare PIN
CAZZZ07475ZOtherBLUE SHIELD OF CALIFORNIA
CAB6334ZMedicare PIN
CAWA91250AMedicare PIN