Provider Demographics
NPI:1528407012
Name:ST. JOHN CRITICAL CARE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:ST. JOHN CRITICAL CARE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HANY
Authorized Official - Middle Name:S
Authorized Official - Last Name:AZIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-326-9999
Mailing Address - Street 1:PO BOX 11134
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93389-1134
Mailing Address - Country:US
Mailing Address - Phone:661-326-9999
Mailing Address - Fax:661-326-9011
Practice Address - Street 1:3805 SAN DIMAS ST
Practice Address - Street 2:STE B
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-5724
Practice Address - Country:US
Practice Address - Phone:661-326-9999
Practice Address - Fax:661-326-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89185207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty