Provider Demographics
NPI:1275559411
Name:SCENIC FACULTY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SCENIC FACULTY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DELEGATED OFFICIAL
Authorized Official - Phone:209-558-7248
Mailing Address - Street 1:PO BOX 577197
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-7197
Mailing Address - Country:US
Mailing Address - Phone:209-558-7248
Mailing Address - Fax:209-558-8723
Practice Address - Street 1:917 OAKDALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4593
Practice Address - Country:US
Practice Address - Phone:209-558-7248
Practice Address - Fax:209-558-8723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
207V00000X, 208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084462Medicaid
CAGR0084463Medicaid
CAGR0084464Medicaid
CAGR0084461Medicaid
CAGR0084466Medicaid
CAGR0084460Medicaid
CAGR0084465Medicaid
ZZZ23887ZMedicare PIN
CAGR0084460Medicaid
ZZZ16265ZMedicare PIN
CAGR0084463Medicaid
CAGR0084464Medicaid
ZZZ16254ZMedicare PIN
CAGR0084461Medicaid