=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114968765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCED PULMONARY MEDICAL ASSOC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2006
-----------------------------------------------------
Last Update Date | 03/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 W OLIVE AVE. STE 103
-----------------------------------------------------
City | MERCED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-526-8038
-----------------------------------------------------
Fax | 209-526-6841
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 780 W OLIVE AVE. STE 103
-----------------------------------------------------
City | MERCED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-723-0783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NICK MADDOCKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-526-8038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | GR0045160
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------