Provider Demographics
NPI:1669575718
Name:PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:EBERSOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-894-6868
Mailing Address - Street 1:30650 RANCHO CALIFORNIA RD STE D406-145
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3215
Mailing Address - Country:US
Mailing Address - Phone:951-894-6868
Mailing Address - Fax:951-894-6860
Practice Address - Street 1:25405 HANCOCK AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5982
Practice Address - Country:US
Practice Address - Phone:951-894-6868
Practice Address - Fax:951-894-6860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC431720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB22449Medicare UPIN
CA00C431720Medicare ID - Type Unspecified