MEDICARE: WEST SACRAMENTOPEDIATRIC MEDICAL GROUP,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	261Q00000X	Clinic/Center	208000000X	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0101570	OTHER	CA	GROUP NUMBER FOR CHDP
2	1841836	OTHER	CA	PIN

General Provider Information

NPI Number	:	1215009212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST SACRAMENTOPEDIATRIC MEDICAL GROUP,INC

Provider Business Mailing Address
First Line	:	1050 JEFFERSON BLVD
Second Line	:
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-3304
Country	:	US
Telephone Number	:	916-371-3787
Fax Number	:	916-371-3790

Provider Business Practice Location Address
First Line	:	1050 JEFFERSON BLVD
Second Line	:
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-3304
Country	:	US
Telephone Number	:	916-371-3787
Fax Number	:	916-371-3790

Authorized Official
Title or Position	:	PROVIDER, CO-OWNER
Name	:	MS. JUDITH J TARRANT
Credential	:	RN,FNP
Telephone Number	:	916-371-3787

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	09/17/2008

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