Provider Demographics
NPI:1801568910
Name:PATINA MEDICAL GROUP, PC
Entity type:Organization
Organization Name:PATINA MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PRIMARY CARE PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RISTOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-999-7137
Mailing Address - Street 1:150 MONUMENT RD
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1702
Mailing Address - Country:US
Mailing Address - Phone:855-478-8208
Mailing Address - Fax:
Practice Address - Street 1:150 MONUMENT RD
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1702
Practice Address - Country:US
Practice Address - Phone:949-246-3344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty