Healthcare Provider Details

I. General information

NPI: 1992008668
Provider Name (Legal Business Name): MADERA MULTI SPECIALTY GROUP, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E ALMOND AVE
MADERA CA
93637-5606
US

IV. Provider business mailing address

1250 E ALMOND AVE
MADERA CA
93637-5606
US

V. Phone/Fax

Practice location:
  • Phone: 559-675-5599
  • Fax: 559-675-5598
Mailing address:
  • Phone: 559-675-5599
  • Fax: 559-675-5598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG70273
License Number StateCA

VIII. Authorized Official

Name: BETTY R CATES
Title or Position: IPA COORDINATOR
Credential:
Phone: 559-675-5599