Provider Demographics
NPI:1982601167
Name:ROMIE LANE PEDIATRIC GROUP, INC
Entity Type:Organization
Organization Name:ROMIE LANE PEDIATRIC GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOEHNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-422-9001
Mailing Address - Street 1:610 E ROMIE LN
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-4209
Mailing Address - Country:US
Mailing Address - Phone:831-422-9001
Mailing Address - Fax:831-422-0577
Practice Address - Street 1:610 E ROMIE LN
Practice Address - Street 2:SUITE #2
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-4209
Practice Address - Country:US
Practice Address - Phone:831-422-9001
Practice Address - Fax:831-422-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-04
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21938174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A41429Medicare UPIN