Provider Demographics
NPI:1578958450
Name:CLINIC SERVICES OF CALIFORNIA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CLINIC SERVICES OF CALIFORNIA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-924-1600
Mailing Address - Street 1:5000 HOPYARD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3348
Mailing Address - Country:US
Mailing Address - Phone:925-924-1600
Mailing Address - Fax:
Practice Address - Street 1:1235 W VINE ST
Practice Address - Street 2:SUITE 20
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5144
Practice Address - Country:US
Practice Address - Phone:925-924-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA157357Medicare PIN