1255536173 NPI number — EMERYVILLE MULTISPECIALTY MEDICAL GROUP PROFESSIONAL CORPORATION

Table of content: (NPI 1255536173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255536173 NPI number — EMERYVILLE MULTISPECIALTY MEDICAL GROUP PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERYVILLE MULTISPECIALTY MEDICAL GROUP PROFESSIONAL CORPORATION
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:
ALAMEDA CENTRE PHYSICIANS
Provider Other Organization Name Type Code:
3
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:
1255536173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1560
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94501-0173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-769-1118
Provider Business Mailing Address Fax Number:
510-769-1119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 S SHORE CTR W
Provider Second Line Business Practice Location Address:
SUITE 103C
Provider Business Practice Location Address City Name:
ALAMEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94501-5762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-769-1118
Provider Business Practice Location Address Fax Number:
510-769-1119
Provider Enumeration Date:
06/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KONG
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
510-769-1118

Provider Taxonomy Codes

  • Taxonomy code: 202C00000X , with the licence number:  A76128 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: A84509 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A76128 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: A84509 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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