Provider Demographics
NPI:1821394875
Name:HURST OSTEOPATHIC MEDICINE, A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:HURST OSTEOPATHIC MEDICINE, A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:209-833-0272
Mailing Address - Street 1:1530 BESSIE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3080
Mailing Address - Country:US
Mailing Address - Phone:209-833-0272
Mailing Address - Fax:209-839-8473
Practice Address - Street 1:1530 BESSIE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3080
Practice Address - Country:US
Practice Address - Phone:209-833-0272
Practice Address - Fax:209-839-8473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8081207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX80810Medicaid
CAH49614Medicare UPIN