Provider Demographics
NPI:1275647737
Name:ROSEVILLE PEDIATRIC MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:ROSEVILLE PEDIATRIC MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNELL
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:SERDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-789-1798
Mailing Address - Street 1:1098 SUNRISE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4469
Mailing Address - Country:US
Mailing Address - Phone:916-789-1798
Mailing Address - Fax:916-789-0889
Practice Address - Street 1:1098 SUNRISE AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4469
Practice Address - Country:US
Practice Address - Phone:916-789-1798
Practice Address - Fax:916-789-0889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA029336261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2146331Medicare UPIN
CA33843ZZMedicare UPIN