Provider Demographics
NPI:1598066748
Name:GREATER SACRAMENTO MED CLINIC
Entity Type:Organization
Organization Name:GREATER SACRAMENTO MED CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRUNG
Authorized Official - Middle Name:THANH
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-363-8888
Mailing Address - Street 1:515 MICHIGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-2705
Mailing Address - Country:US
Mailing Address - Phone:916-363-8888
Mailing Address - Fax:
Practice Address - Street 1:515 MICHIGAN BLVD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-2705
Practice Address - Country:US
Practice Address - Phone:916-363-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37275208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD71770Medicare UPIN
CA00A372750Medicare PIN