Provider Demographics
NPI:1295166189
Name:COUNTRY MEDICAL CORPORATION
Entity type:Organization
Organization Name:COUNTRY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BHARATI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-860-2610
Mailing Address - Street 1:23341 GOLDEN SPRINGS DR
Mailing Address - Street 2:SUITE #210
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2058
Mailing Address - Country:US
Mailing Address - Phone:909-860-2610
Mailing Address - Fax:909-860-1192
Practice Address - Street 1:23341 GOLDEN SPRINGS DR
Practice Address - Street 2:SUITE #210
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2058
Practice Address - Country:US
Practice Address - Phone:909-860-2610
Practice Address - Fax:909-860-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36684207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28161Medicare UPIN