Provider Demographics
NPI:1730223421
Name:CARRILLO MEDICAL GROUP PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CARRILLO MEDICAL GROUP PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:INES
Authorized Official - Middle Name:
Authorized Official - Last Name:SJOGRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-790-0760
Mailing Address - Street 1:1800 SULLIVAN AVE RM 101
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2227
Mailing Address - Country:US
Mailing Address - Phone:650-994-0459
Mailing Address - Fax:
Practice Address - Street 1:1800 SULLIVAN AVE RM 101
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2227
Practice Address - Country:US
Practice Address - Phone:650-994-0459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A517430Medicaid
CA00A517430Medicaid
ZZZ02763ZMedicare PIN