Provider Demographics
NPI:1700017142
Name:TRIBUNE MEDICAL GROUP
Entity Type:Organization
Organization Name:TRIBUNE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C; PA-C
Authorized Official - Phone:661-865-8893
Mailing Address - Street 1:PO BOX 22096
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93390-2096
Mailing Address - Country:US
Mailing Address - Phone:661-865-8893
Mailing Address - Fax:
Practice Address - Street 1:1818 NILES ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-4910
Practice Address - Country:US
Practice Address - Phone:661-865-8893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3604747208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID