Provider Demographics
NPI:1821162884
Name:GILROY FAMILY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:GILROY FAMILY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:F
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-842-3133
Mailing Address - Street 1:9460 NO NAME UNO
Mailing Address - Street 2:#115
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020
Mailing Address - Country:US
Mailing Address - Phone:408-842-3133
Mailing Address - Fax:408-842-2229
Practice Address - Street 1:9460 NO NAME UNO
Practice Address - Street 2:#115
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020
Practice Address - Country:US
Practice Address - Phone:408-842-3133
Practice Address - Fax:408-842-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57748ZOtherBLUE SHIELD
CACI2190Medicare PIN
CAZZZ18883ZMedicare PIN