Provider Demographics
NPI:1073761805
Name:JPS PHYSICIAN GROUP INC.
Entity Type:Organization
Organization Name:JPS PHYSICIAN GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CORBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-921-3431
Mailing Address - Street 1:19801 ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4103
Mailing Address - Country:US
Mailing Address - Phone:650-743-6473
Mailing Address - Fax:
Practice Address - Street 1:1617 HEMPHILL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4709
Practice Address - Country:US
Practice Address - Phone:817-852-8440
Practice Address - Fax:817-927-3603
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JPS PHYSICIAN GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty