Provider Demographics
NPI:1285855130
Name:REBONG PEDIATRIC MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:REBONG PEDIATRIC MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:REBONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-729-3232
Mailing Address - Street 1:145 N JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1918
Mailing Address - Country:US
Mailing Address - Phone:408-729-3232
Mailing Address - Fax:408-729-2165
Practice Address - Street 1:145 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1918
Practice Address - Country:US
Practice Address - Phone:408-729-3232
Practice Address - Fax:408-729-2165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty