Provider Demographics
NPI:1093353195
Name:EAST SACRAMENTO PEDIATRIC MEDICAL GROUP INC
Entity Type:Organization
Organization Name:EAST SACRAMENTO PEDIATRIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:KHAIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-451-8430
Mailing Address - Street 1:5030 J ST STE 301
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3800
Mailing Address - Country:US
Mailing Address - Phone:916-451-8430
Mailing Address - Fax:
Practice Address - Street 1:5030 J ST STE 301
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3800
Practice Address - Country:US
Practice Address - Phone:916-451-8430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1588600431Medicaid
CA1811383490Medicaid
CA1902842354Medicaid