Provider Demographics
NPI:1275678880
Name:PHYSICAL MEDICINE GROUP INC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE GROUP INC
Other - Org Name:MARKET ST CHIROPRACTIC SAN RAMON REGIONAL CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MELEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:415-782-2273
Mailing Address - Street 1:388 MARKET ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-5312
Mailing Address - Country:US
Mailing Address - Phone:415-982-2273
Mailing Address - Fax:415-982-2282
Practice Address - Street 1:388 MARKET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94111-5311
Practice Address - Country:US
Practice Address - Phone:415-982-2273
Practice Address - Fax:415-982-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26102111N00000X
CADC25753111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0261020Medicare ID - Type Unspecified
CADC0257530Medicare ID - Type Unspecified