Provider Demographics
NPI:1457445215
Name:PHYSICIANS NETWORK SERVICES MEDICAL GROUP
Entity Type:Organization
Organization Name:PHYSICIANS NETWORK SERVICES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:TABB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:714-572-2039
Mailing Address - Street 1:377 E CHAPMAN AVE
Mailing Address - Street 2:STE 240
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5091
Mailing Address - Country:US
Mailing Address - Phone:714-572-2039
Mailing Address - Fax:
Practice Address - Street 1:377 E CHAPMAN AVE
Practice Address - Street 2:STE 240
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-5091
Practice Address - Country:US
Practice Address - Phone:714-572-2039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD003040Medicaid
CACI6599Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CAW14339Medicare ID - Type Unspecified
CAGSD003040Medicaid
CAZZZ15073ZMedicare ID - Type Unspecified
CAW14339Medicare PIN