Provider Demographics
NPI:1801985874
Name:SANTA CRUZ NEPHROLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SANTA CRUZ NEPHROLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILU
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKATANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-476-1551
Mailing Address - Street 1:1595 SOQUEL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1721
Mailing Address - Country:US
Mailing Address - Phone:831-476-1551
Mailing Address - Fax:831-476-3241
Practice Address - Street 1:1595 SOQUEL DR.
Practice Address - Street 2:STE. 210
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1721
Practice Address - Country:US
Practice Address - Phone:831-476-1551
Practice Address - Fax:831-476-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72787207RN0300X
CAA76684207RN0300X
CAA32324207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ66323ZOtherBLUE SHIELD PROVIDER ID
CADD5840OtherMEDICARE RR GROUP#
CA00A320240Medicaid
CAG96519Medicare UPIN
CAA87599Medicare UPIN
CADD5840OtherMEDICARE RR GROUP#
CAI08185Medicare UPIN