Provider Demographics
NPI:1962405860
Name:PMK MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:PMK MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE & QUALITY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:805-485-8709
Mailing Address - Street 1:1700 N ROSE AVE
Mailing Address - Street 2:STE 320
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-7648
Mailing Address - Country:US
Mailing Address - Phone:805-485-8709
Mailing Address - Fax:805-485-5521
Practice Address - Street 1:1700 N ROSE AVE STE 320
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7648
Practice Address - Country:US
Practice Address - Phone:805-485-8709
Practice Address - Fax:805-485-5521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncologyGroup - Single Specialty
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064440Medicaid
CAZZZ45387ZOtherBLUE SHIELD PROVIDER
CA5628497OtherNCPDP/NPDS
W13337OtherMEDICARE PTAN
CAH80708Medicare UPIN
1028830001Medicare NSC
CAA46503Medicare UPIN
W13337OtherMEDICARE PTAN
CAA86452Medicare UPIN
CAG52976Medicare UPIN
I66446Medicare UPIN