Provider Demographics
NPI:1457439572
Name:MERIDIAN MEDICAL GROUP PROFESSIONAL CORP
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL GROUP PROFESSIONAL CORP
Other - Org Name:MERIDIAN MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-754-8988
Mailing Address - Street 1:1047 E CAPITOL EXPY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-2415
Mailing Address - Country:US
Mailing Address - Phone:408-754-8988
Mailing Address - Fax:408-754-8289
Practice Address - Street 1:1047 E CAPITOL EXPY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-2415
Practice Address - Country:US
Practice Address - Phone:408-754-8988
Practice Address - Fax:408-754-8289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA303360208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA880357380OtherTAX ID
CAGR0070181Medicaid
CAGR0070182Medicaid
CA00A303360OtherMEDICAL LICENSE NUMBER
CA1134228752OtherNPI NUMBER
CAZZZ41448ZOtherBLUE SHIELD NUMBER
CAGR0070180Medicaid
CAMMM00292MMedicare ID - Type UnspecifiedGROUP NUMBER
CAGR0070180Medicaid