Provider Demographics
NPI:1457495046
Name:FALLBROOK MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:FALLBROOK MEDICAL GROUP, INC
Other - Org Name:FALLBROOK MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-731-0352
Mailing Address - Street 1:504 E ALVARADO ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-2364
Mailing Address - Country:US
Mailing Address - Phone:760-731-0352
Mailing Address - Fax:760-731-2151
Practice Address - Street 1:504 E ALVARADO ST STE 201
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-2364
Practice Address - Country:US
Practice Address - Phone:760-731-0352
Practice Address - Fax:760-731-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23092207Q00000X
CAC36017207R00000X
CAG36388208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR00666880Medicaid
CAW13565Medicare ID - Type Unspecified