Provider Demographics
NPI:1689614562
Name:VALLEY HEART ASSOCIATES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:VALLEY HEART ASSOCIATES MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MERILLAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-577-5557
Mailing Address - Street 1:1540 FLORIDA AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4430
Mailing Address - Country:US
Mailing Address - Phone:209-577-5557
Mailing Address - Fax:209-579-7246
Practice Address - Street 1:1540 FLORIDA AVE
Practice Address - Street 2:STE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4430
Practice Address - Country:US
Practice Address - Phone:209-577-5557
Practice Address - Fax:209-579-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76734ZOtherPTAN
CAZZZ76734ZMedicaid