Provider Demographics
NPI:1801181151
Name:GREATER MODESTO MEDICAL SURGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:GREATER MODESTO MEDICAL SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PORTEOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-577-3388
Mailing Address - Street 1:1541 FLORIDA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4423
Mailing Address - Country:US
Mailing Address - Phone:209-577-3388
Mailing Address - Fax:209-523-0764
Practice Address - Street 1:205 W GRANGER AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4402
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:209-523-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD069AOtherMEDICARE GROUP PTAN