Provider Demographics
NPI:1013046200
Name:CENTER MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CENTER MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-793-2645
Mailing Address - Street 1:1999 MOWRY AVE
Mailing Address - Street 2:SUITE N
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1738
Mailing Address - Country:US
Mailing Address - Phone:510-793-2645
Mailing Address - Fax:510-791-6846
Practice Address - Street 1:1999 MOWRY AVE
Practice Address - Street 2:SUITE N
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1738
Practice Address - Country:US
Practice Address - Phone:510-793-2645
Practice Address - Fax:510-791-6846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID NUMBER