Provider Demographics
NPI:1992710768
Name:HERA OBGYN MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:HERA OBGYN MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-521-4372
Mailing Address - Street 1:1552 COFFEE RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3107
Mailing Address - Country:US
Mailing Address - Phone:209-521-4372
Mailing Address - Fax:209-523-2005
Practice Address - Street 1:1552 COFFEE RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3107
Practice Address - Country:US
Practice Address - Phone:209-521-4372
Practice Address - Fax:209-523-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04654ZOtherBLUE SHIELD OF CA
CAGR01402490Medicaid