Provider Demographics
NPI:1710168919
Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT. OF NEPHROLOGY
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT. OF NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5700
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:SE13
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-5770
Mailing Address - Fax:559-353-5822
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:SE13
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-5770
Practice Address - Fax:559-353-5822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR007868AMedicaid