Provider Demographics
NPI:1932380383
Name:MERIDIAN MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-624-5288
Mailing Address - Street 1:PO BOX 3278
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95156-3278
Mailing Address - Country:US
Mailing Address - Phone:209-624-5288
Mailing Address - Fax:209-624-5289
Practice Address - Street 1:330 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3139
Practice Address - Country:US
Practice Address - Phone:209-624-5288
Practice Address - Fax:209-624-5289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0070180Medicaid
CAGR0070181Medicaid
CAZZZ41448ZOtherBLUE SHIELD
CA1457439572OtherNPI NUMBER
CA1972602464OtherNPI NUMBERS
CA1730273855OtherNPI NUMBERS
CAGR0070182Medicaid
CA1134228752OtherNPI NUMBER
CA1720171598OtherNPI NUMBER
CA1730273855OtherNPI NUMBERS
CAMMM00292MMedicare UPIN
CAE25220Medicare UPIN
CAGR0070181Medicaid