Provider Demographics
NPI:1083639850
Name:COMMUNITY PERINATOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:COMMUNITY PERINATOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:559-228-4298
Mailing Address - Street 1:PO BOX 28913
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8913
Mailing Address - Country:US
Mailing Address - Phone:559-228-4298
Mailing Address - Fax:559-224-3920
Practice Address - Street 1:110 N VALERIA ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2166
Practice Address - Country:US
Practice Address - Phone:559-233-7700
Practice Address - Fax:559-233-7744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48104174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100510Medicaid
CAZZZ23315ZMedicare PIN