Provider Demographics
NPI:1639135510
Name:GREWAL MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:GREWAL MEDICAL ASSOCIATES
Other - Org Name:TRACY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISS
Authorized Official - Middle Name:
Authorized Official - Last Name:MILTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-835-4232
Mailing Address - Street 1:530 W EATON AVE STE K
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376
Mailing Address - Country:US
Mailing Address - Phone:209-835-4232
Mailing Address - Fax:209-835-3246
Practice Address - Street 1:530 W EATON AVE STE K
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376
Practice Address - Country:US
Practice Address - Phone:209-835-4232
Practice Address - Fax:209-835-3246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40558207Q00000X
CAA53793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01049ZMedicare ID - Type UnspecifiedMEDICARE