Provider Demographics
NPI: | 1477554012 |
---|---|
Name: | DAVITA MEDICAL GROUP TALBERT CALIFORNIA, P.C. |
Entity Type: | Organization |
Organization Name: | DAVITA MEDICAL GROUP TALBERT CALIFORNIA, P.C. |
Other - Org Name: | TALBERT MEDICAL GROUP |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SECRETARY |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOHN |
Authorized Official - Middle Name: | G |
Authorized Official - Last Name: | LIETHEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 952-205-6262 |
Mailing Address - Street 1: | P.O. BOX 6400 |
Mailing Address - Street 2: | |
Mailing Address - City: | TORRANCE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90504-6400 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-783-5552 |
Mailing Address - Fax: | 310-783-5581 |
Practice Address - Street 1: | 1236 N MAGNOLIA AVE |
Practice Address - Street 2: | |
Practice Address - City: | ANAHEIM |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92801-2607 |
Practice Address - Country: | US |
Practice Address - Phone: | 714-995-1000 |
Practice Address - Fax: | 714-828-7926 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-08-04 |
Last Update Date: | 2019-08-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 152W00000X, 207K00000X, 207N00000X, 207PE0004X, 207Q00000X, 207R00000X, 207V00000X, 207W00000X, 207Y00000X, 207ZP0105X, 208000000X, 2084N0400X, 208600000X, 208800000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207PE0004X | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 207ZP0105X | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | GR0077863 | Medicaid | |
CA | W13900F | Medicare PIN |