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General NPI Number Information
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NPI Number | 1417308321
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Entity Type | Organization
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Legal Business Name | PERMANENTE MEDICAL GROUP
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Dates
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Enumeration Date | 06/22/2016
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Last Update Date | 06/22/2016
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Provider Practice Location Address
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Address Line | 1955 COWELL BLVD
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City | DAVIS
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State | CA
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Zip | 95618-6325
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Country | US
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Telephone | 530-757-4157
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Fax |
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Provider Business Mailing Address
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Address Line | 1955 COWELL BLVD
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City | DAVIS
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State | CA
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Zip | 95618-6325
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DPM
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Name | BARRY SCURRAN
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Credential |
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Telephone | 510-987-4026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A49994
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License Number State | CA
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