Provider Demographics
NPI:1578618088
Name:OLIVERIO MEDICAL GROUP
Entity Type:Organization
Organization Name:OLIVERIO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLIVERIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-849-1950
Mailing Address - Street 1:330 W RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4823
Mailing Address - Country:US
Mailing Address - Phone:951-849-1950
Mailing Address - Fax:951-849-0080
Practice Address - Street 1:330 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4823
Practice Address - Country:US
Practice Address - Phone:951-849-1950
Practice Address - Fax:951-849-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A450420207Q00000X
CA00A332270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0057980Medicaid
CAZZZ33480ZMedicare ID - Type Unspecified
CAA27080Medicare UPIN
CAA03196Medicare UPIN