Provider Demographics
NPI:1205877156
Name:ENLOE PRIMARY PHYSICIANS MEDICAL GROUP A MEDICAL CORPORATION
Entity type:Organization
Organization Name:ENLOE PRIMARY PHYSICIANS MEDICAL GROUP A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:COURTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-896-7455
Mailing Address - Street 1:1209 ESPLANADE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3397
Mailing Address - Country:US
Mailing Address - Phone:530-896-7455
Mailing Address - Fax:530-896-1832
Practice Address - Street 1:1531 ESPLANADE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3310
Practice Address - Country:US
Practice Address - Phone:530-896-7455
Practice Address - Fax:530-896-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0092720Medicaid
CAGR0092720Medicaid