Provider Demographics
NPI:1023062171
Name:GRASS VALLEY CARDIOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:GRASS VALLEY CARDIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-477-7265
Mailing Address - Street 1:150 CATHERINE LN
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5719
Mailing Address - Country:US
Mailing Address - Phone:530-477-8358
Mailing Address - Fax:530-477-2015
Practice Address - Street 1:150 CATHERINE LANE D
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-477-8358
Practice Address - Fax:530-477-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA222237372Medicare ID - Type Unspecified