Provider Demographics
NPI:1598832172
Name:GERIATRIC PODIATRY MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:GERIATRIC PODIATRY MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:TABB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-599-0981
Mailing Address - Street 1:425 W BONITA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2543
Mailing Address - Country:US
Mailing Address - Phone:909-599-0981
Mailing Address - Fax:909-592-0738
Practice Address - Street 1:425 W BONITA AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:909-599-0981
Practice Address - Fax:909-592-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE000050Medicaid
CACJ3207OtherPALMETTO GBA
CAGRE000052Medicaid
CAW15303Medicare PIN
CACJ3207OtherPALMETTO GBA
CAGRE000050Medicaid
CAWE2478DMedicare PIN
CA480032496Medicare PIN
CAT11349Medicare UPIN