Provider Demographics
NPI:1013515287
Name:BALWIN PARK MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BALWIN PARK MEDICAL GROUP, INC.
Other - Org Name:BALWIN PARK MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERRAJITH
Authorized Official - Middle Name:BERTRAND R
Authorized Official - Last Name:DE SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:714-673-2603
Mailing Address - Street 1:14652 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-5333
Mailing Address - Country:US
Mailing Address - Phone:626-337-1360
Mailing Address - Fax:626-962-1375
Practice Address - Street 1:14652 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5333
Practice Address - Country:US
Practice Address - Phone:626-337-1360
Practice Address - Fax:323-962-1375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-11
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty