Provider Demographics
NPI: | 1437111028 |
---|---|
Name: | CHAPARRAL MEDICAL GROUP, INC. |
Entity Type: | Organization |
Organization Name: | CHAPARRAL MEDICAL GROUP, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | PRASAD |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | JEEREDDI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 909-398-1550 |
Mailing Address - Street 1: | 840 TOWNE CENTER DRIVE |
Mailing Address - Street 2: | |
Mailing Address - City: | POMONA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 91767-5900 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 909-398-1550 |
Mailing Address - Fax: | 909-398-1488 |
Practice Address - Street 1: | 1866 N ORANGE GROVE AVE |
Practice Address - Street 2: | 202 201 102 & 104 |
Practice Address - City: | POMONA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 91767-3031 |
Practice Address - Country: | US |
Practice Address - Phone: | 909-623-8796 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-04-06 |
Last Update Date: | 2023-06-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207PH0002X, 207R00000X, 207RC0000X, 207RC0001X, 207RC0200X, 207RG0100X, 207RG0300X, 207RP1001X, 207RR0500X, 207X00000X, 2084N0400X | ||
CA | 207RE0101X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207PH0002X | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine | Group - Multi-Specialty |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RC0001X | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | Group - Multi-Specialty |
No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | GR0052950 | Medicaid | |
CA | CS2119 | Medicare PIN | |
CA | GR0052950 | Medicaid |