Provider Demographics
NPI:1073065512
Name:CENTRAL CALIFORNIA CHEST SURGERY
Entity Type:Organization
Organization Name:CENTRAL CALIFORNIA CHEST SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CONTRACTING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPERNAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-935-5491
Mailing Address - Street 1:729 N MEDICAL CENTER DR W STE 223
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6885
Mailing Address - Country:US
Mailing Address - Phone:559-449-9990
Mailing Address - Fax:559-449-9991
Practice Address - Street 1:729 N MEDICAL CENTER DR W STE 223
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6885
Practice Address - Country:US
Practice Address - Phone:559-449-9990
Practice Address - Fax:559-449-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99566208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty