=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487739942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMERON PARK MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 10/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3581 PALMER DR STE. 401
-----------------------------------------------------
City | CAMERON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95682-8236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-676-7337
-----------------------------------------------------
Fax | 530-676-1141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3581 PALMER DR STE. 401
-----------------------------------------------------
City | CAMERON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95682-8236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-676-7337
-----------------------------------------------------
Fax | 530-676-1141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. KAREN L MINGLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-676-7337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | G52556
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------