=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114007432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERINATAL & PEDIATRIC SPECIALISTS MEDICAL GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 07/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 F ST STE 313
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-736-6470
-----------------------------------------------------
Fax | 916-736-6798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5301 F ST STE 313
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-736-6470
-----------------------------------------------------
Fax | 916-736-6798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. ANDREW WERTZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 916-736-6470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 105882
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------