Provider Demographics
NPI:1558354373
Name:PELLEGRIN BROAD MORSE & MOY MDS & DO
Entity Type:Organization
Organization Name:PELLEGRIN BROAD MORSE & MOY MDS & DO
Other - Org Name:LOS GATOS FAMILY PHYSICIANS MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE/FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-354-4030
Mailing Address - Street 1:143 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-6903
Mailing Address - Country:US
Mailing Address - Phone:408-354-3920
Mailing Address - Fax:408-354-0782
Practice Address - Street 1:143 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-6903
Practice Address - Country:US
Practice Address - Phone:408-354-3920
Practice Address - Fax:408-354-0782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41377 G67157 G75242207Q00000X
CAG41377 G75242 A55016207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CJ4068OtherRR MCR
FNP22360OtherFICT NAME PERMIT
CJ4068OtherRR MCR