Provider Demographics
NPI:1871630541
Name:VENTANA MEDICAL GROUP, APC
Entity Type:Organization
Organization Name:VENTANA MEDICAL GROUP, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-378-1888
Mailing Address - Street 1:476 E CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2142
Mailing Address - Country:US
Mailing Address - Phone:408-378-1888
Mailing Address - Fax:408-378-5830
Practice Address - Street 1:476 E CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2142
Practice Address - Country:US
Practice Address - Phone:408-378-1888
Practice Address - Fax:408-378-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G602961207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE35502Medicare UPIN