Provider Demographics
NPI:1881730661
Name:WESTSIDE MEDICAL GROUP OF MENDOTA INC.
Entity type:Organization
Organization Name:WESTSIDE MEDICAL GROUP OF MENDOTA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:G
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-655-1000
Mailing Address - Street 1:450 OLLER ST
Mailing Address - Street 2:SUITE#101
Mailing Address - City:MENDOTA
Mailing Address - State:CA
Mailing Address - Zip Code:93640-2313
Mailing Address - Country:US
Mailing Address - Phone:559-655-1000
Mailing Address - Fax:
Practice Address - Street 1:450 OLLER ST
Practice Address - Street 2:SUITE#101
Practice Address - City:MENDOTA
Practice Address - State:CA
Practice Address - Zip Code:93640-2313
Practice Address - Country:US
Practice Address - Phone:559-655-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08916FMedicaid
CA058916Medicare Oscar/Certification