Provider Demographics
NPI:1700871001
Name:ANN EWALT HAMILTON MD MEDICAL CORP
Entity Type:Organization
Organization Name:ANN EWALT HAMILTON MD MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:EWALT
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-788-0210
Mailing Address - Street 1:4294 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3827
Mailing Address - Country:US
Mailing Address - Phone:951-788-0210
Mailing Address - Fax:951-788-6330
Practice Address - Street 1:4294 ORANGE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3827
Practice Address - Country:US
Practice Address - Phone:951-788-0210
Practice Address - Fax:951-788-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G224280Medicaid
CAZZZ28676ZMedicare PIN
CA00G224280Medicaid