Provider Demographics
NPI:1255544557
Name:PITUCK MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:PITUCK MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-223-0396
Mailing Address - Street 1:432 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-2025
Mailing Address - Country:US
Mailing Address - Phone:714-223-0396
Mailing Address - Fax:714-223-0397
Practice Address - Street 1:5858 MAGNOLIA AVE STE C
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1886
Practice Address - Country:US
Practice Address - Phone:714-223-0396
Practice Address - Fax:714-223-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13983ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER