MEDICARE: BIG VALLEY OB-GYN MEDICAL CENTER,INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	20A5298	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073619060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG VALLEY OB-GYN MEDICAL CENTER,INC.

Provider Business Mailing Address
First Line	:	420 W ACACIA ST
Second Line	:	SUITE 11
City	:	STOCKTON
State	:	CA
Zip	:	95203-2441
Country	:	US
Telephone Number	:	209-948-4098
Fax Number	:	209-948-2334

Provider Business Practice Location Address
First Line	:	420 W ACACIA ST
Second Line	:	SUITE 11
City	:	STOCKTON
State	:	CA
Zip	:	95203-2441
Country	:	US
Telephone Number	:	209-948-4098
Fax Number	:	209-948-2334

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	ROBERT CHARLES SOUTHMAYD
Credential	:	D.O.
Telephone Number	:	209-948-4098

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	08/26/2015

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Directions to “BIG VALLEY OB-GYN MEDICAL CENTER,INC. ” Practice Location

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