Provider Demographics
NPI:1669507752
Name:CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:P
Authorized Official - Last Name:VAN GUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-453-5200
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:1247 E ALLUVIAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2686
Practice Address - Country:US
Practice Address - Phone:559-431-6226
Practice Address - Fax:559-440-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC4679OtherRAILROAD MEDICARE
CAGR0014818Medicaid
CAGR0014818Medicaid