Provider Demographics
NPI:1801945647
Name:JOHN MUIR TRAUMA PHYSICIAN MEDICAL GROUP
Entity type:Organization
Organization Name:JOHN MUIR TRAUMA PHYSICIAN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-941-2159
Mailing Address - Street 1:1400 TREAT BLVD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2142
Mailing Address - Country:US
Mailing Address - Phone:925-947-5331
Mailing Address - Fax:925-941-2177
Practice Address - Street 1:1601 YGNACIO VALLEY RD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3122
Practice Address - Country:US
Practice Address - Phone:925-947-5331
Practice Address - Fax:925-941-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0028140Medicaid