Provider Demographics
NPI:1336106897
Name:AVANT INPATIENT SERVICES MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:AVANT INPATIENT SERVICES MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:JESSOP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-889-5082
Mailing Address - Street 1:PO BOX 26529
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92799-6529
Mailing Address - Country:US
Mailing Address - Phone:714-689-1500
Mailing Address - Fax:714-918-0135
Practice Address - Street 1:20103 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5341
Practice Address - Country:US
Practice Address - Phone:510-889-5082
Practice Address - Fax:510-733-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087602Medicaid
CAGR0087602Medicaid