Provider Demographics
NPI:1700964665
Name:THE PEDIATRIC SPECIALISTS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:THE PEDIATRIC SPECIALISTS MEDICAL GROUP, INC.
Other - Org Name:PEDIATRIC SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-481-3166
Mailing Address - Street 1:138 W BRANCH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2611
Mailing Address - Country:US
Mailing Address - Phone:805-481-3166
Mailing Address - Fax:805-481-8237
Practice Address - Street 1:138 W BRANCH ST
Practice Address - Street 2:SUITE A
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2611
Practice Address - Country:US
Practice Address - Phone:805-481-3166
Practice Address - Fax:805-481-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55326208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ50949YOtherBLUE SHIELD
CAGR0105730Medicaid