Provider Demographics
NPI:1720271059
Name:PEDIATRIC AND ASTHMA CLINIC
Entity Type:Organization
Organization Name:PEDIATRIC AND ASTHMA CLINIC
Other - Org Name:MEDFIRST PHYSICIANS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:HIDALGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:671-647-4121
Mailing Address - Street 1:428 CHALAN SAN ANTONIO
Mailing Address - Street 2:P & F PROFESSIONAL MANOR SUITE 101
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:671-647-4121
Mailing Address - Fax:671-646-4429
Practice Address - Street 1:428 CHALAN SAN ANTONIO
Practice Address - Street 2:P & F PROFESSIONAL MANOR SUITE 101
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-647-4121
Practice Address - Fax:671-646-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU57194Medicare PIN