Provider Demographics
NPI:1235322694
Name:FAMILY PRACTICE PHYSICIANS A MEDICAL CORPORATION
Entity type:Organization
Organization Name:FAMILY PRACTICE PHYSICIANS A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ADELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-963-4559
Mailing Address - Street 1:20932 BROOKHURST ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-6638
Mailing Address - Country:US
Mailing Address - Phone:714-963-4559
Mailing Address - Fax:714-963-0631
Practice Address - Street 1:20932 BROOKHURST ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-6638
Practice Address - Country:US
Practice Address - Phone:714-963-4559
Practice Address - Fax:714-963-0631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0021840Medicaid
CAW9915Medicare PIN
CAGR0021840Medicaid