Provider Demographics
NPI:1033391313
Name:PACIFIC MED & NEPHROLOGY
Entity Type:Organization
Organization Name:PACIFIC MED & NEPHROLOGY
Other - Org Name:PACIFIC MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MERSEDEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-649-7232
Mailing Address - Street 1:736 ROUTE 4
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SINAJANA
Mailing Address - State:GU
Mailing Address - Zip Code:96910
Mailing Address - Country:US
Mailing Address - Phone:671-649-7232
Mailing Address - Fax:671-649-7233
Practice Address - Street 1:736 ROUTE 4
Practice Address - Street 2:SUITE 103
Practice Address - City:SINAJANA
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-649-7232
Practice Address - Fax:671-649-7233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU261QM1300X261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH52062Medicare PIN