Provider Demographics
NPI:1932469749
Name:MISCO MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MISCO MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:FERAMISCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-870-9301
Mailing Address - Street 1:31566 RAILROAD CANYON RD
Mailing Address - Street 2:2-130
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9446
Mailing Address - Country:US
Mailing Address - Phone:877-870-9301
Mailing Address - Fax:877-882-0462
Practice Address - Street 1:1125 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1418
Practice Address - Country:US
Practice Address - Phone:877-870-9301
Practice Address - Fax:877-882-0462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty