Provider Demographics
NPI:1396811535
Name:CLOVIS MEDICAL GROUP INC
Entity type:Organization
Organization Name:CLOVIS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-299-7294
Mailing Address - Street 1:221 W FIR AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-0223
Mailing Address - Country:US
Mailing Address - Phone:559-299-7294
Mailing Address - Fax:559-299-0641
Practice Address - Street 1:221 W FIR AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-0223
Practice Address - Country:US
Practice Address - Phone:559-299-7294
Practice Address - Fax:559-299-0641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G99171Medicare UPIN
E23201Medicare UPIN
A41241Medicare UPIN