Provider Demographics
NPI:1003955758
Name:LASSEN MEDICAL GROUP INC
Entity Type:Organization
Organization Name:LASSEN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-528-4477
Mailing Address - Street 1:2450 SISTER MARY COLUMBA DR
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-4356
Mailing Address - Country:US
Mailing Address - Phone:530-527-0141
Mailing Address - Fax:530-527-3720
Practice Address - Street 1:2450 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4356
Practice Address - Country:US
Practice Address - Phone:530-527-0141
Practice Address - Fax:530-527-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53955FMedicaid
CALAB18474GMedicaid
CAGR0089250Medicaid
CALAB18474FMedicaid
CARHM53955FMedicaid
CALAB18474GMedicaid