1679507172 NPI number — WILLIAM SUTHERLING M.D., A MEDICAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679507172 NPI number — WILLIAM SUTHERLING M.D., A MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM SUTHERLING M.D., A MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EPILEPSY AND BRAIN MAPPING PROGRAM, A MEDICAL GROUP, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679507172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 CONGRESS ST
Provider Second Line Business Mailing Address:
SUITE 505
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91105-3045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-792-7300
Provider Business Mailing Address Fax Number:
626-792-7336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 CONGRESS ST
Provider Second Line Business Practice Location Address:
SUITE 505
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91105-3045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-792-7300
Provider Business Practice Location Address Fax Number:
626-792-7336
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUTHERLING
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
626-792-7300

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  G45896 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0100610 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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