Provider Demographics
NPI:1275691339
Name:MED-1 MEDICAL CENTER PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MED-1 MEDICAL CENTER PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:290-574-1355
Mailing Address - Street 1:3508 DALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-0552
Mailing Address - Country:US
Mailing Address - Phone:209-574-1355
Mailing Address - Fax:209-571-8204
Practice Address - Street 1:3508 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-0552
Practice Address - Country:US
Practice Address - Phone:209-574-1355
Practice Address - Fax:209-571-8204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75606261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26254OtherLICENCE NUMBER
CAPT23734OtherLICENCE NUMBER
CAG75606OtherLICENCE NUMBER
CA13661OtherLICENCE NUMBER
CA16903OtherLICENCE NUMBER
CA18301OtherLICENCE NUMBER
CA26062OtherLICENCE NUMBER
CA27743Other27743
CA28332OtherLICENCE NUMBER
CADC0167900OtherLICENCE NUMBER
CA15489OtherLICENCE NUMBER
CA25608OtherLICENCE NUMBER
CA160480OtherLICENCE NUMBER
CA28612OtherLICENCE NUMBER
CAA52975OtherLICENCE NUMBER
CAFL32707OtherLICENCE NUMBER
CANP13918OtherLICENCE NUMBER
CAG9700OtherLICENCE NUMBER
CACFE33570OtherLICENCE NUMBER
CAG66831OtherLICENCE NUMBER