Provider Demographics
NPI:1598845562
Name:MEDIWELL, INC.
Entity Type:Organization
Organization Name:MEDIWELL, INC.
Other - Org Name:MEDIWELL MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAVDEEP
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:BHASIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-458-9355
Mailing Address - Street 1:1733 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3457
Mailing Address - Country:US
Mailing Address - Phone:916-458-9355
Mailing Address - Fax:916-458-9353
Practice Address - Street 1:1733 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3457
Practice Address - Country:US
Practice Address - Phone:916-458-9355
Practice Address - Fax:916-458-9353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055920261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28024ZOtherMEDICARE GROUP NUMBER
CAGR0095610Medicaid
CAZZZ28024ZOtherMEDICARE GROUP NUMBER