Provider Demographics
NPI:1013964220
Name:WILDWOOD MEDICAL, A MEDICAL CORP.
Entity Type:Organization
Organization Name:WILDWOOD MEDICAL, A MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:GINNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BACKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-477-6830
Mailing Address - Street 1:11244 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946
Mailing Address - Country:US
Mailing Address - Phone:530-432-4937
Mailing Address - Fax:530-432-5261
Practice Address - Street 1:11244 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946
Practice Address - Country:US
Practice Address - Phone:530-432-4937
Practice Address - Fax:530-432-5261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A33078Medicare UPIN
ZZZ21364ZMedicare ID - Type Unspecified