Provider Demographics
NPI:1134279904
Name:PA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PA MEDICAL GROUP INC
Other - Org Name:DBA: PEDIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DRUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-356-1319
Mailing Address - Street 1:2577 SAMARITAN DR
Mailing Address - Street 2:SUITE 830
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4100
Mailing Address - Country:US
Mailing Address - Phone:408-356-1319
Mailing Address - Fax:408-356-6296
Practice Address - Street 1:2577 SAMARITAN DR
Practice Address - Street 2:SUITE 830
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4100
Practice Address - Country:US
Practice Address - Phone:408-356-1319
Practice Address - Fax:408-356-6296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA70876OtherSTATE LICENSE
CAG84517OtherSTATE LICENSE
CAG77403OtherSTATE LICENSE
CAA64948OtherSTATE LICENSE
CAA51788OtherSTATE LICENSE