Provider Demographics
NPI:1396720371
Name:PACIFIC PEDIATRIC CARDIOLOGY MED GRP INC
Entity type:Organization
Organization Name:PACIFIC PEDIATRIC CARDIOLOGY MED GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-796-9259
Mailing Address - Street 1:50 W BELLEFONTAINE ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3132
Mailing Address - Country:US
Mailing Address - Phone:626-796-9259
Mailing Address - Fax:626-449-8560
Practice Address - Street 1:50 W BELLEFONTAINE ST
Practice Address - Street 2:SUITE 405
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3132
Practice Address - Country:US
Practice Address - Phone:626-796-9259
Practice Address - Fax:626-449-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086740Medicaid
CAZZZ609882OtherBCBS
CAW14906Medicare ID - Type Unspecified