Provider Demographics
NPI:1316040488
Name:CHANWELL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CHANWELL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ESTRELLITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-270-8668
Mailing Address - Street 1:10615 S DE ANZA BLVD
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-4431
Mailing Address - Country:US
Mailing Address - Phone:408-343-0888
Mailing Address - Fax:408-343-0688
Practice Address - Street 1:10615 S DE ANZA BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-4431
Practice Address - Country:US
Practice Address - Phone:408-343-0888
Practice Address - Fax:408-343-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0052602Medicaid
CAZZZ45859ZMedicare PIN