Provider Demographics
NPI:1467672345
Name:HERR-KOSTIC MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:HERR-KOSTIC MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELCIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-772-2823
Mailing Address - Street 1:41-120 WASHINGTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203
Mailing Address - Country:US
Mailing Address - Phone:760-772-2823
Mailing Address - Fax:760-772-2819
Practice Address - Street 1:41-120 WASHINGTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203
Practice Address - Country:US
Practice Address - Phone:760-772-2823
Practice Address - Fax:760-772-2819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID
CAG62424Medicare UPIN
CAC59289Medicare UPIN