Provider Demographics
NPI:1811091952
Name:PEDIATRIC MEDICAL GROUP OF SANTA MARIA INC
Entity type:Organization
Organization Name:PEDIATRIC MEDICAL GROUP OF SANTA MARIA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROSTERMUNDT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-922-3548
Mailing Address - Street 1:1430 E MAIN ST
Mailing Address - Street 2:#201
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-922-3548
Mailing Address - Fax:805-928-5609
Practice Address - Street 1:1430 E MAIN ST
Practice Address - Street 2:#201
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-922-3548
Practice Address - Fax:805-928-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48371YMedicaid