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General NPI Number Information
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NPI Number | 1073619060
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Entity Type | Organization
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Legal Business Name | BIG VALLEY OB-GYN MEDICAL CENTER,INC.
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 08/26/2015
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Provider Practice Location Address
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Address Line | 420 W ACACIA ST SUITE 11
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City | STOCKTON
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State | CA
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Zip | 95203-2441
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Country | US
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Telephone | 209-948-4098
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Fax | 209-948-2334
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Provider Business Mailing Address
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Address Line | 420 W ACACIA ST SUITE 11
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City | STOCKTON
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State | CA
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Zip | 95203-2441
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Country | US
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Telephone | 209-948-4098
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Fax | 209-948-2334
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Authorized Official
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Title or Position | PHYSICIAN
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Name | ROBERT CHARLES SOUTHMAYD
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Credential | D.O.
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Telephone | 209-948-4098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 20A5298
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License Number State | CA
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