Provider Demographics
NPI:1366474876
Name:BLACKHAWK MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:BLACKHAWK MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-736-7070
Mailing Address - Street 1:4165 BLACKHAWK PLAZA CIR
Mailing Address - Street 2:#100
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4904
Mailing Address - Country:US
Mailing Address - Phone:925-736-7070
Mailing Address - Fax:925-736-7075
Practice Address - Street 1:4165 BLACKHAWK PLAZA CIR
Practice Address - Street 2:#100
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4904
Practice Address - Country:US
Practice Address - Phone:925-736-7070
Practice Address - Fax:925-736-7075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00501ZMedicare ID - Type Unspecified