Provider Demographics
NPI:1932366614
Name:BLOSS MEMORIAL DISTRICT HOSPITAL CASTLE FAMILY HLTH CTR & ADULT DAYCAR
Entity Type:Organization
Organization Name:BLOSS MEMORIAL DISTRICT HOSPITAL CASTLE FAMILY HLTH CTR & ADULT DAYCAR
Other - Org Name:CASTLE FAMILY HEALTH PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:HILARIO
Authorized Official - Last Name:LUJAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-381-2000
Mailing Address - Street 1:3605 HOSPITAL RD STE H
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5173
Mailing Address - Country:US
Mailing Address - Phone:209-381-2000
Mailing Address - Fax:209-726-0278
Practice Address - Street 1:3605 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-5173
Practice Address - Country:US
Practice Address - Phone:209-381-2000
Practice Address - Fax:209-726-0278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81776207RP1001X
CAG60458207V00000X
CAC50290207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADUR0420FMedicaid
CARHM18515FMedicaid
CARHM18537FMedicaid
CARHM03997FMedicaid
CARHM18537FMedicaid
CAADUR0420FMedicaid
CARHM03997FMedicaid