Provider Demographics
NPI:1205857398
Name:GLEN CITY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:GLEN CITY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SWARTOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-933-6622
Mailing Address - Street 1:247 MARCH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-2511
Mailing Address - Country:US
Mailing Address - Phone:805-933-6622
Mailing Address - Fax:806-933-6629
Practice Address - Street 1:247 MARCH ST
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-2511
Practice Address - Country:US
Practice Address - Phone:805-933-6622
Practice Address - Fax:806-933-6629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ82993ZMedicaid
CAZZZ82993ZMedicaid