1154464329 NPI number — PENINSULA ORTHOPEDIC ASSOCIATES, INC.

Table of content: (NPI 1154464329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154464329 NPI number — PENINSULA ORTHOPEDIC ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA ORTHOPEDIC ASSOCIATES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154464329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1850 SULLIVAN AVE STE 330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALY CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94015-2204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-756-5630
Provider Business Mailing Address Fax Number:
650-994-1155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 SULLIVAN AVE STE 330
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALY CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94015-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-756-5630
Provider Business Practice Location Address Fax Number:
650-994-1155
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONRAD
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
650-756-5630

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 0208450001 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0053110 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com