MEDICARE: VERICARE OF CALIFORNIA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	1041C0700X	Clinical Social Worker	CA
2	2084P0800X	Psychiatry Physician	CA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	CA
4	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	CA
5	103TC0700X	Clinical Psychologist	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CH5753	OTHER	CA	RAILROAD MEDICARE

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	:	1760437271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VERICARE OF CALIFORNIA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	55 HATCHETTS HILL RD
Second Line	:
City	:	OLD LYME
State	:	CT
Zip	:	06371-1534
Country	:	US
Telephone Number	:	800-370-3651
Fax Number	:	877-515-7147

Provider Business Practice Location Address
First Line	:	1505 COLBY DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-3307
Country	:	US
Telephone Number	:	800-257-8715
Fax Number	:	800-819-1655

Authorized Official
Title or Position	:	DIRECTOR, CREDENTIALING ENROLLMENT
Name	:	MELISSA KING
Credential	:
Telephone Number	:	800-370-3651

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/11/2017

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