Provider Demographics
NPI:1568522878
Name:PREMIER URGENT CARE A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PREMIER URGENT CARE A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:TRACY OCCUPATIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGDISH
Authorized Official - Middle Name:AMBALAL
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-832-8984
Mailing Address - Street 1:644 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3437
Mailing Address - Country:US
Mailing Address - Phone:209-832-8984
Mailing Address - Fax:209-832-8988
Practice Address - Street 1:644 W 12TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3437
Practice Address - Country:US
Practice Address - Phone:209-832-8984
Practice Address - Fax:209-832-8988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31816207Q00000X
CAA855092207Q00000X
CA20A7496207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A7496OtherSTATE LICENSE DR. PULLIAM
CABH8637881OtherDR. HUBLI BNDD NUMBER
CAA31816OtherSTATE LICENSE DR. PATEL
CA00A85126Medicaid
CABP4399944OtherDR. PULLIAM BNDD NUMBER
CAA855092OtherSTATE LICENSE DR. HUBLI
CAAP8331112OtherDR. PATEL BNDD NUMBER
CA00A318160Medicaid
CA05D0695064903593OtherCLIA NUMBER
CAAP8331112OtherBNDD NUMBER
CA20A7496OtherSTATE LICENSE DR. PULLIAM
CAA855092OtherSTATE LICENSE DR. HUBLI