Provider Demographics
NPI:1992899942
Name:PEDIATRIC & ADOLESCENT MEDICAL ASSOC. OF THE PACIFIC COAST
Entity type:Organization
Organization Name:PEDIATRIC & ADOLESCENT MEDICAL ASSOC. OF THE PACIFIC COAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:KELLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-757-8124
Mailing Address - Street 1:260 SAN JOSE ST
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3901
Mailing Address - Country:US
Mailing Address - Phone:831-757-8124
Mailing Address - Fax:731-757-4790
Practice Address - Street 1:260 SAN JOSE ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3901
Practice Address - Country:US
Practice Address - Phone:831-757-8124
Practice Address - Fax:731-757-4790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR009600Medicaid