Provider Demographics
NPI:1063500106
Name:PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-252-8588
Mailing Address - Street 1:27699 JEFFERSON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2661
Mailing Address - Country:US
Mailing Address - Phone:951-252-8588
Mailing Address - Fax:951-252-8589
Practice Address - Street 1:26900 NEWPORT RD
Practice Address - Street 2:SUITE 107
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-9222
Practice Address - Country:US
Practice Address - Phone:951-301-5380
Practice Address - Fax:951-301-5390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0088823OtherMEDI-CAL
CAGR0088823OtherMEDI-CAL