Provider Demographics
NPI:1184654923
Name:DOCTORS MEDICAL CENTER OF MODESTO, INC.
Entity Type:Organization
Organization Name:DOCTORS MEDICAL CENTER OF MODESTO, INC.
Other - Org Name:DOCTORS MEDICAL CENTER OF MODESTO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-576-3790
Mailing Address - Street 1:PO BOX 57376
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7376
Mailing Address - Country:US
Mailing Address - Phone:209-578-2513
Mailing Address - Fax:209-576-3680
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4405
Practice Address - Country:US
Practice Address - Phone:209-578-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000026282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP30464GMedicaid
661516980OtherAETNA US HEALTHCARE (NATI
CAHSP40464HMedicaid
000414OtherHUMANA
CAHSP40464GMedicaid
ZZZA0464ZOtherBS OF CALIFORNIA
012821-0001OtherPACIFICARE OF CALIFORNIA
CAHSC30464HMedicaid
CAHSP40464HMedicaid
05-0464Medicare PIN