Provider Demographics
NPI:1629053723
Name:SPLINTER MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SPLINTER MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PEVSNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-394-9090
Mailing Address - Street 1:1334 W COVINA BLVD
Mailing Address - Street 2:#103
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3211
Mailing Address - Country:US
Mailing Address - Phone:909-394-9090
Mailing Address - Fax:909-394-9696
Practice Address - Street 1:1334 W COVINA BLVD
Practice Address - Street 2:#103
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3211
Practice Address - Country:US
Practice Address - Phone:909-394-9090
Practice Address - Fax:909-394-9696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16471Medicare UPIN
CAW20A5383BMedicare ID - Type Unspecified