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General NPI Number Information
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NPI Number | 1548494974
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Entity Type | Organization
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Legal Business Name | GREATER MODESTO MEDICAL SURGICAL ASSOCIATES, INC.
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Dates
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Enumeration Date | 05/13/2009
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Last Update Date | 10/05/2009
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Provider Practice Location Address
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Address Line | 200 COTTAGE AVE SUITE 101
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City | MANTECA
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State | CA
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Zip | 95336-4935
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Country | US
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Telephone | 209-577-3388
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Fax | 209-342-3743
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Provider Business Mailing Address
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Address Line | 1541 FLORIDA AVE SUITE 200
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City | MODESTO
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State | CA
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Zip | 95350-4429
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Country | US
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Telephone | 209-577-3388
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Fax | 209-342-3743
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Authorized Official
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Title or Position | SHAREHOLDER
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Name | MR. JOHN R PORTEOUS
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Credential | M.D.
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Telephone | 209-577-3388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2088P0231X
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Taxonomy Name | Pediatric Urology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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