Healthcare Provider Details

I. General information

NPI: 1033489307
Provider Name (Legal Business Name): GREATER MODESTO MEDICAL SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 CONANT AVE
MODESTO CA
95350-6527
US

IV. Provider business mailing address

1541 FLORIDA AVE SUITE 200
MODESTO CA
95350-4423
US

V. Phone/Fax

Practice location:
  • Phone: 209-214-7053
  • Fax: 209-523-0764
Mailing address:
  • Phone: 209-577-3388
  • Fax: 209-523-0764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN R PORTEOUS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 209-577-3388