Provider Demographics
NPI:1639205917
Name:NEPHROLOGY MED ASSOCS CHO
Entity Type:Organization
Organization Name:NEPHROLOGY MED ASSOCS CHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD OF DEPT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-428-3335
Mailing Address - Street 1:3116 W MARCH LN
Mailing Address - Street 2:STE 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2369
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6543
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3335
Practice Address - Fax:510-450-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG319272080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095810OtherMEDI-CAL
CAG31927OtherDR MORRELL'S CA MD LICENS