Provider Demographics
NPI:1578750121
Name:WELLSPRING FAMILY MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPRING FAMILY MEDICAL GROUP
Other - Org Name:WELLSPRING FAMILY MEDICAL GROUP OF VENTURA COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-639-9332
Mailing Address - Street 1:5850 THILLE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5413
Mailing Address - Country:US
Mailing Address - Phone:805-639-9332
Mailing Address - Fax:805-639-9367
Practice Address - Street 1:5850 THILLE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5413
Practice Address - Country:US
Practice Address - Phone:805-639-9332
Practice Address - Fax:805-639-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21936Medicare PIN