Provider Demographics
NPI:1992104095
Name:CARDIOTHORACIC SURGERY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:CARDIOTHORACIC SURGERY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-255-8825
Mailing Address - Street 1:3010 BEARD RD
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3442
Mailing Address - Country:US
Mailing Address - Phone:707-255-8825
Mailing Address - Fax:
Practice Address - Street 1:3434 VILLA LN
Practice Address - Street 2:SUITE 380
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6405
Practice Address - Country:US
Practice Address - Phone:707-254-9693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73011208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA144809Medicare PIN