Provider Demographics
NPI:1891131298
Name:FIRST PEDIATRICS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:FIRST PEDIATRICS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MYDILI
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANIAM-MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-435-1500
Mailing Address - Street 1:6255 N FRESNO ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5271
Mailing Address - Country:US
Mailing Address - Phone:559-435-1500
Mailing Address - Fax:559-478-5082
Practice Address - Street 1:6255 N FRESNO ST
Practice Address - Street 2:SUITE 106
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5271
Practice Address - Country:US
Practice Address - Phone:559-435-1500
Practice Address - Fax:559-478-5082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54039174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC54039OtherLICENSE NUMBER
CAC54717OtherLICENSE NUMBER