Provider Demographics
NPI:1245386218
Name:GOLDEN STATE PHYSICIANS MEDICAL GROUP
Entity Type:Organization
Organization Name:GOLDEN STATE PHYSICIANS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-271-3200
Mailing Address - Street 1:900 E MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5853
Mailing Address - Country:US
Mailing Address - Phone:530-271-3200
Mailing Address - Fax:530-274-6347
Practice Address - Street 1:900 E MAIN ST STE 301
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:530-271-3200
Practice Address - Fax:530-274-6347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization