Provider Demographics
NPI:1619922911
Name:PITTSBURG-ANTIOCH MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PITTSBURG-ANTIOCH MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:SPRINGHILL MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEL RIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-635-2978
Mailing Address - Street 1:2220 GLADSTONE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-5123
Mailing Address - Country:US
Mailing Address - Phone:924-432-3318
Mailing Address - Fax:
Practice Address - Street 1:2220 GLADSTONE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-5123
Practice Address - Country:US
Practice Address - Phone:924-432-3318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50205207Q00000X
207R00000X, 207RP1001X
CAA836250207RE0101X
CAG43569207RI0011X
CAA82612207RP1001X
CAG32797207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053010Medicaid
CO00A826120Medicaid
CACS2543OtherRAILROAD MEDICARE
CA00G327970Medicaid
CA00A651470Medicaid
CA00A502050Medicaid
CA00G435690Medicaid
CA00A836250Medicaid
CAZZZ34060ZOtherBLUE SHIELD PROVIDER NUMB
CO00A826120Medicaid
CA00A651470Medicaid
CAGR0053010Medicaid
CAF24050Medicare UPIN
CAZZZ34060ZMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
CA00G435690Medicaid