Provider Demographics
NPI:1295718849
Name:MEDSTOPS MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:MEDSTOPS MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-549-8880
Mailing Address - Street 1:283 MADONNA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-5432
Mailing Address - Country:US
Mailing Address - Phone:805-549-8880
Mailing Address - Fax:805-783-2009
Practice Address - Street 1:283 MADONNA RD
Practice Address - Street 2:SUITE B
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5432
Practice Address - Country:US
Practice Address - Phone:805-549-8880
Practice Address - Fax:805-783-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22211568261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
184356300OtherUSDL/ACS
5482188OtherAETNA
CAZZZ00436ZOtherBLUE SHIELD OF CALIFORNIA
CAW14937Medicare ID - Type UnspecifiedGROUP MEDICARE BILLING #