Provider Demographics
NPI:1073681730
Name:VISALIA FAMILY PRACTICE MEDICAL GROUP
Entity Type:Organization
Organization Name:VISALIA FAMILY PRACTICE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BREANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-625-9200
Mailing Address - Street 1:107 N HALL ST STE D
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-5850
Mailing Address - Country:US
Mailing Address - Phone:559-625-9200
Mailing Address - Fax:559-625-0665
Practice Address - Street 1:107 N HALL ST STE D
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5850
Practice Address - Country:US
Practice Address - Phone:559-625-9200
Practice Address - Fax:559-625-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX IDENTIFICATION NUMBER
CAZZZ16151ZMedicare ID - Type UnspecifiedFAMILY PRACTICE