NPIMap

Organization Active NPI

Aspen Family Medical Group of Modesto, Inc.

Doing business as Premium Mental Health Services

  • Family Medicine Physician
  • Modesto, CA
National Provider Identifier
1467533737
Registry record updated Aug 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ASPEN FAMILY MEDICAL GROUP OF MODESTO, INC.
Doing business as
Premium Mental Health Services
Practice address
1130 Coffee Rd Ste 10
Modesto, CA 95355-4228
Phone
(209) 522-9054
Fax
(209) 522-2631
NPI assigned
Oct 17, 2006
Last updated
Aug 13, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 13, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mariela Gutierrez, MEDICAL ASSISTANT
Title
Clinic Supervisor
Phone
(209) 522-9054

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X

Addresses

Primary practice location

1130 Coffee Rd Ste 10
Modesto, CA 95355-4228

Mailing address

1130 Coffee Rd Ste 10
Modesto, CA 95355-4228
Phone (209) 522-9054

Other names 1

  • Premium Mental Health Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040519000541 CA Part B Supplier - Clinic/Group Practice 4183615248 Receives reassigned benefits from 6 practitioners
Practice locations: Modesto, CA; Stockton, CA

National Provider Directory

National Provider Directory
Tax ID family
Aspen Family Medical Group of Modesto Inc3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1630 N Edison St
Stockton, CA 95204
Phone (209) 948-8762

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161043200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1723507200000",
    "number": "1467533737",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1130 COFFEE RD STE 10",
            "city": "MODESTO",
            "state": "CA",
            "postal_code": "953554228",
            "telephone_number": "209-522-9054",
            "fax_number": "209-522-2631"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1130 COFFEE RD STE 10",
            "city": "MODESTO",
            "state": "CA",
            "postal_code": "953554228",
            "telephone_number": "209-522-9054",
            "fax_number": "209-522-2631"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ASPEN FAMILY MEDICAL GROUP OF MODESTO, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-17",
        "last_updated": "2024-08-13",
        "certification_date": "2024-08-12",
        "status": "A",
        "authorized_official_last_name": "GUTIERREZ",
        "authorized_official_first_name": "MARIELA",
        "authorized_official_title_or_position": "CLINIC SUPERVISOR",
        "authorized_official_telephone_number": "209-522-9054",
        "authorized_official_credential": "MEDICAL ASSISTANT"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Premium Mental Health Services",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Premium Mental Health Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Modesto, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.