Provider Demographics
NPI:1750562336
Name:PROSPICE MEDICAL GROUP CORPORATION
Entity type:Organization
Organization Name:PROSPICE MEDICAL GROUP CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SHORTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-932-6208
Mailing Address - Street 1:3065 RICHMOND PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-5719
Mailing Address - Country:US
Mailing Address - Phone:510-932-6208
Mailing Address - Fax:
Practice Address - Street 1:4770 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-1065
Practice Address - Country:US
Practice Address - Phone:559-226-6824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2008-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77502208VP0000X
CAA46453207X00000X
CAG10280207T00000X
CAA40212208100000X
CAC35999207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty