Provider Demographics
NPI:1245280718
Name:FAMILY HEALTH CENTRE MEDICAL GROUP
Entity type:Organization
Organization Name:FAMILY HEALTH CENTRE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VASUKI
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:SITTAMPALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-872-4311
Mailing Address - Street 1:686 W LINE ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3315
Mailing Address - Country:US
Mailing Address - Phone:760-872-4311
Mailing Address - Fax:760-872-4130
Practice Address - Street 1:686 W LINE ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3315
Practice Address - Country:US
Practice Address - Phone:760-872-4311
Practice Address - Fax:760-872-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC371720207Q00000X
CAY201575363L00000X
CAA93866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA002086560Medicaid
CARHM53941FMedicaid
CAGR0021672Medicaid
CA0205422OtherST OF WA DEPT LABOR INDUS
CA183283900OtherOWCP
CARHM53941FMedicaid
CA553941Medicare ID - Type Unspecified
CA002086560Medicaid
CA080026203Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
CAP19451Medicare UPIN
CAGR0021672Medicaid