Provider Demographics
NPI: | 1497702724 |
---|---|
Name: | CADUCEUS PHYSICIANS MEDICAL GROUP |
Entity Type: | Organization |
Organization Name: | CADUCEUS PHYSICIANS MEDICAL GROUP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GREGG |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DENICOLA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 714-646-8000 |
Mailing Address - Street 1: | 18200 YORBA LINDA BLVD STE 111 |
Mailing Address - Street 2: | |
Mailing Address - City: | YORBA LINDA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92886-4043 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 714-646-8000 |
Mailing Address - Fax: | 714-572-2562 |
Practice Address - Street 1: | 18200 YORBA LINDA BLVD STE 250 |
Practice Address - Street 2: | |
Practice Address - City: | YORBA LINDA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92886-4044 |
Practice Address - Country: | US |
Practice Address - Phone: | 714-646-8000 |
Practice Address - Fax: | 714-572-2562 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-30 |
Last Update Date: | 2023-04-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 133N00000X, 207Q00000X, 207R00000X, 207T00000X, 207V00000X, 207X00000X, 207Y00000X, 208000000X, 208800000X, 213E00000X, 225100000X, 225700000X, 247100000X, 363AM0700X | |
261QU0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225700000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | Group - Multi-Specialty | |
No | 247100000X | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Group - Multi-Specialty | |
No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | Group - Multi-Specialty |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 05D0938185 | Other | CLIA |
CA | ZZZ58296Z | Other | BLUE SHIELD |
CA | GR0084863 | Medicaid | |
CA | ZZZ58296Z | Other | BLUE SHIELD |
CA | A49390 | Medicare UPIN |