=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154404085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TCS MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 12/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 CHERRYHILL TRL
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96003-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-605-8013
-----------------------------------------------------
Fax | 866-647-3121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 991826
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96099-1826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-244-5833
-----------------------------------------------------
Fax | 866-647-3121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DOUGLAS H MCCONNELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 530-605-8013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A24881
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------