Provider Demographics
NPI:1497785455
Name:SAN JOAQUIN CARDIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SAN JOAQUIN CARDIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALDERSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-942-1005
Mailing Address - Street 1:2800 N CALIFORNIA ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-942-1005
Mailing Address - Fax:209-942-0455
Practice Address - Street 1:2800 N CALIFORNIA ST STE 14
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3759
Practice Address - Country:US
Practice Address - Phone:209-942-1005
Practice Address - Fax:209-942-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0062380Medicaid
CACC6353OtherRAILROAD MEDICARE
CACC6353OtherRAILROAD MEDICARE