Healthcare Provider Details

I. General information

NPI: 1952693178
Provider Name (Legal Business Name): MEDICAL GROUP OF SAN JOAQUIN VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 F ST SUITE 250
BAKERSFIELD CA
93301-1839
US

IV. Provider business mailing address

3201 F ST SUITE 250
BAKERSFIELD CA
93301-1839
US

V. Phone/Fax

Practice location:
  • Phone: 661-322-7500
  • Fax: 661-322-7510
Mailing address:
  • Phone: 661-322-7500
  • Fax: 661-322-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG16783
License Number StateCA

VIII. Authorized Official

Name: DR. CHARLES ROY PHILLIPS
Title or Position: OWNER
Credential: M.D.
Phone: 661-322-7500