| Carrillo Medical Group Professional Corporation | |
|
1800 Sullivan Ave Rm 101 Daly City CA 94015-2227 | |
| (650) 994-0459 | |
| Not Available |
| Full Name | Carrillo Medical Group Professional Corporation |
|---|---|
| Speciality | Family Medicine |
| Location | 1800 Sullivan Ave Rm 101, Daly City, California |
| Authorized Official Name and Position | Ines Sjogrell (MANAGER) |
| Authorized Official Contact | 9257900760 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Carrillo Medical Group Professional Corporation 1800 Sullivan Ave Rm 101 Daly City CA 94015-2227 Ph: (650) 994-0459 | Carrillo Medical Group Professional Corporation 1800 Sullivan Ave Rm 101 Daly City CA 94015-2227 Ph: (650) 994-0459 |
| NPI Number | 1730223421 |
|---|---|
| Provider Enumeration Date | 02/16/2007 |
| Last Update Date | 09/15/2015 |
| Medicare PECOS PAC ID | 1052342029 |
|---|---|
| Medicare Enrollment ID | O20050830000368 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730223421 | NPI | - | NPPES |
| 00A517430 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | A51743 (California) | Primary |
| Provider Name | Lornalyn J Carrillo |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1558383844 PECOS PAC ID: 8123059110 Enrollment ID: I20050901000433 |
| Provider Name | Connie Y Tan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1679211015 PECOS PAC ID: 8527442607 Enrollment ID: I20220909000134 |
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