=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760256721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GSP PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2023
-----------------------------------------------------
Last Update Date | 11/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 E SHAW AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-7608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-840-3991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1830 W ASHLAN AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93705-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-840-3991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MANAVJEET SIDHU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 559-840-3991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------