Provider Demographics
NPI:1013983113
Name:NORTHWEST PHYSICIANS MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTHWEST PHYSICIANS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:JELINEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-271-6365
Mailing Address - Street 1:4770 W HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-8401
Mailing Address - Country:US
Mailing Address - Phone:559-271-6365
Mailing Address - Fax:559-271-6326
Practice Address - Street 1:4770 W HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-8401
Practice Address - Country:US
Practice Address - Phone:559-271-6365
Practice Address - Fax:559-271-6326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACC6650OtherMEDICARE RR
CAGR0064290Medicaid
CAGR0064290Medicaid