=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063803203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRAMENTO PEDIATRICS MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2015
-----------------------------------------------------
Last Update Date | 02/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7501 HOSPITAL DR SUITE 206
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-5405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-682-7481
-----------------------------------------------------
Fax | 916-422-6500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7237 E SOUTHGATE DR SUITE A
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-422-6635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEPHANIE ANNE WALTON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 916-422-6635
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A34512
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------