Provider Demographics
NPI:1992008668
Name:MADERA MULTI SPECIALTY GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MADERA MULTI SPECIALTY GROUP, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IPA COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-675-5599
Mailing Address - Street 1:1250 E ALMOND AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-5606
Mailing Address - Country:US
Mailing Address - Phone:559-675-5599
Mailing Address - Fax:559-675-5598
Practice Address - Street 1:1250 E ALMOND AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5606
Practice Address - Country:US
Practice Address - Phone:559-675-5599
Practice Address - Fax:559-675-5598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70273207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty