Healthcare Provider Details

I. General information

NPI: 1013983113
Provider Name (Legal Business Name): NORTHWEST PHYSICIANS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 W HERNDON AVE
FRESNO CA
93722-8401
US

IV. Provider business mailing address

4770 W HERNDON AVE
FRESNO CA
93722-8401
US

V. Phone/Fax

Practice location:
  • Phone: 559-271-6365
  • Fax: 559-271-6326
Mailing address:
  • Phone: 559-271-6365
  • Fax: 559-271-6326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA E JELINEK
Title or Position: ADMINISTRATOR
Credential:
Phone: 559-271-6365