Provider Demographics
NPI:1902947252
Name:FRESNO NEUROSURGICAL MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:FRESNO NEUROSURGICAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:V.
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-281-4936
Mailing Address - Street 1:7797 N 1ST ST # 18
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0962
Mailing Address - Country:US
Mailing Address - Phone:559-281-4936
Mailing Address - Fax:559-298-3540
Practice Address - Street 1:7797 N 1ST ST # 18
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0962
Practice Address - Country:US
Practice Address - Phone:559-281-4936
Practice Address - Fax:559-298-3540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG14465207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36318Medicare UPIN
CAA39256Medicare UPIN