Provider Demographics
NPI:1891840088
Name:CENTRAL COAST URGENT CARE MEDICAL GROUP
Entity Type:Organization
Organization Name:CENTRAL COAST URGENT CARE MEDICAL GROUP
Other - Org Name:CENTRAL COAST URGENT CARE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-922-0561
Mailing Address - Street 1:PO BOX 848722
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8722
Mailing Address - Country:US
Mailing Address - Phone:805-922-0561
Mailing Address - Fax:805-922-0083
Practice Address - Street 1:340 EAST BETTERAVIA RD
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7847
Practice Address - Country:US
Practice Address - Phone:805-922-0561
Practice Address - Fax:805-922-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG48284AOtherMEDICARE PPIN
CAWA50123BOtherMEDICARE PPIN
CAWPT10965BOtherMEDICARE PPIN
CA1245327840OtherNPI
CAWG61780EOtherMEDICARE PPIN
CAWPT8518AOtherMEDICARE PPIN
CA1083643878OtherNPI
CA1376510529OtherNPI
CAW8259OtherMEDICARE GROUP ID
CA1609965433OtherNPI
CAZZZ16208ZOtherBLUE SHIELD
CA1437246022OtherNPI
CA1891840088OtherNPI
CAWG32607AOtherMEDICARE PPIN
CAWG61780EOtherMEDICARE PPIN