Provider Demographics
NPI:1235310335
Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF EMANUEL
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF EMANUEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5700
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-5700
Mailing Address - Fax:559-353-5708
Practice Address - Street 1:825 DELBON AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2016
Practice Address - Country:US
Practice Address - Phone:209-664-5065
Practice Address - Fax:209-664-5067
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR007868GMedicaid