=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194196832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2015
-----------------------------------------------------
Last Update Date | 10/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1806 WADSWORTH AVENUE
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-748-1687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1806 WADSWORTH AVENUE
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-748-1687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. MATTHEW TATE
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 805-748-1687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | PA19685
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------