Provider Demographics
NPI:1366185118
Name:CHANNEL MEDICAL GROUP OF CALIFORNIA, P.C.
Entity type:Organization
Organization Name:CHANNEL MEDICAL GROUP OF CALIFORNIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SABA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-463-0650
Mailing Address - Street 1:4 E 27TH ST UNIT 20206
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-9410
Mailing Address - Country:US
Mailing Address - Phone:646-389-3451
Mailing Address - Fax:
Practice Address - Street 1:755 BAYWOOD DR FL 2
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5510
Practice Address - Country:US
Practice Address - Phone:646-389-3451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty