Provider Demographics
NPI:1215177787
Name:FOOTHILL PEDIATRICS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:FOOTHILL PEDIATRICS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-532-5524
Mailing Address - Street 1:12791 CABEZUT RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5926
Mailing Address - Country:US
Mailing Address - Phone:209-532-5524
Mailing Address - Fax:209-532-1513
Practice Address - Street 1:12791 CABEZUT RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5926
Practice Address - Country:US
Practice Address - Phone:209-532-5524
Practice Address - Fax:209-532-1513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty