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Organization
NORTH LAKE PEDIATRICS MEDICAL GROUP, INC.
Active
Organization
NORTH LAKE PEDIATRICS MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. CHRISTINE JACOBS M.A.C.M.O.M. (OFFICE MANAGER)
(530) 582-6190
Entity
Organization
Contact information
Practice address
10956 DONNER PASS RD STE 130, TRUCKEE, CA 96161-4860
(530) 587-3523
(530) 587-1004
Mailing address
10956 DONNER PASS RD STE 130, TRUCKEE, CA 96161-4860
(530) 587-3523
(530) 587-1004
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
G35475
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0075020
—
CA
01
—
ZHCPP486
BLUE CROSS PROVIDER NUMBE
CA
01
—
ZZZ52949Z
BLUE SHIELD PROVIDER #
CA
Enumeration date
10/18/2006
Last updated
08/22/2020
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