Provider Demographics
NPI:1427209618
Name:PARADAISE MEDICAL OFFICE
Entity Type:Organization
Organization Name:PARADAISE MEDICAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-558-4000
Mailing Address - Street 1:401 PARADISE RD STE E
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-3163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 PARADISE RD STE E
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-3163
Practice Address - Country:US
Practice Address - Phone:209-558-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1376852889Medicare PIN