Provider Demographics
NPI:1184674830
Name:SAN MARCOS MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:SAN MARCOS MEDICAL GROUP INC.
Other - Org Name:METROPOLITAN FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-376-4438
Mailing Address - Street 1:1574 W BASE LINE ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1736
Mailing Address - Country:US
Mailing Address - Phone:909-881-7320
Mailing Address - Fax:909-881-7330
Practice Address - Street 1:1574 W BASE LINE ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1736
Practice Address - Country:US
Practice Address - Phone:909-881-7320
Practice Address - Fax:909-881-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295384428Medicaid
CACA482046OtherMEDICARE
CA00AX91490Medicaid
CA00C507130Medicaid
CAGR0086720Medicaid
CA00A514170Medicaid
CA00A398050Medicaid
CA00A460220Medicaid
CA00A764460Medicaid