Provider Demographics
| NPI: | 1548343510 |
|---|---|
| Name: | PERMANENTE MEDICAL GROUP INC |
| Entity type: | Organization |
| Organization Name: | PERMANENTE MEDICAL GROUP INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHIEF FINANCIAL OFFICER |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | PATRICIA |
| Authorized Official - Middle Name: | T |
| Authorized Official - Last Name: | WEST |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 510-295-7207 |
| Mailing Address - Street 1: | 5820 OWENS DR. BUILDING E, 2ND FLOOR |
| Mailing Address - Street 2: | TPMG FINANCIAL MANAGEMENT |
| Mailing Address - City: | PLEASANTON |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 94588-3900 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 7373 WEST LANE |
| Practice Address - Street 2: | |
| Practice Address - City: | STOCKTON |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 95210-3377 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 209-476-2000 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | PERMANENTE MEDICAL GROUP, INC. |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-10-23 |
| Last Update Date: | 2024-11-20 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | GR001572H | Medicaid | |
| CA | GRN00011A | Medicaid | |
| CA | LAB89878F | Medicaid | |
| CA | ZZZ83648Z | Medicaid | |
| CA | GR0015720 | Medicaid | |
| CA | GR0015723 | Medicaid | |
| CA | GR0015729 | Medicaid | |
| CA | GR0015724 | Medicaid | |
| CA | GR0046722 | Medicaid | |
| CA | GRN000118 | Medicaid | |
| CA | GR001572R | Medicaid | |
| CA | GR001572C | Medicaid | |
| CA | GR001572G | Medicaid | |
| CA | LAB04213F | Medicaid | |
| CA | ZZZ20738Z | Medicaid | |
| CA | GRN000118 | Medicaid |
