Provider Demographics
NPI:1568474096
Name:PATTERSON AND TEDFORD PEDIATRICS, A CALIFORNIA MEDICAL CORP
Entity Type:Organization
Organization Name:PATTERSON AND TEDFORD PEDIATRICS, A CALIFORNIA MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-466-6622
Mailing Address - Street 1:7700 MORRO RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-4435
Mailing Address - Country:US
Mailing Address - Phone:805-466-6622
Mailing Address - Fax:805-461-0361
Practice Address - Street 1:7700 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4435
Practice Address - Country:US
Practice Address - Phone:805-466-6622
Practice Address - Fax:805-461-0361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2202292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
357801011OtherCIGNA PIN
4315040OtherAETNA PIN
CAGR0089110Medicaid
CAZZZ01321ZOtherBLUE SHIELD OF CA GRP PIN