Provider Demographics
NPI:1144324468
Name:CHANWELL MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:CHANWELL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ESTRELLITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-270-8668
Mailing Address - Street 1:2690 SOUTH WHITE ROAD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2075
Mailing Address - Country:US
Mailing Address - Phone:408-270-8668
Mailing Address - Fax:408-270-8669
Practice Address - Street 1:2690 SOUTH WHITE ROAD
Practice Address - Street 2:SUITE 10
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2075
Practice Address - Country:US
Practice Address - Phone:408-270-8668
Practice Address - Fax:408-270-8669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0052600Medicaid
CAZZZ32613ZMedicare PIN