Provider Demographics
NPI:1235230624
Name:MONTEREY PENINSULA PEDIATRIC MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:MONTEREY PENINSULA PEDIATRIC MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-333-0999
Mailing Address - Street 1:2 UPPER RAGSDALE DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5736
Mailing Address - Country:US
Mailing Address - Phone:831-333-0999
Mailing Address - Fax:831-333-0909
Practice Address - Street 1:2 UPPER RAGSDALE DR
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5736
Practice Address - Country:US
Practice Address - Phone:831-333-0999
Practice Address - Fax:831-333-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG023932208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOC325750Medicaid