Provider Demographics
NPI:1164475299
Name:VERICARE OF CALIFORNIA MEDICAL GROUP
Entity Type:Organization
Organization Name:VERICARE OF CALIFORNIA MEDICAL GROUP
Other - Org Name:VERICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-370-3651
Mailing Address - Street 1:55 HATCHETTS HILL RD
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1534
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:877-515-7147
Practice Address - Street 1:2707 PINE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2522
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2017-07-11
Deactivation Date:2007-04-11
Deactivation Code:
Reactivation Date:2007-08-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPS000150Medicaid
CACC7816OtherRAILROAD MEDICARE
CACC7816OtherRAILROAD MEDICARE