1407877269 NPI number — BAY VALLEY MEDICAL GROUP, INC

Table of content: (NPI 1407877269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407877269 NPI number — BAY VALLEY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY VALLEY MEDICAL GROUP, 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:
1407877269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27212 CALAROGA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94545-4339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-785-5000
Provider Business Mailing Address Fax Number:
510-293-5606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27212 CALAROGA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYWARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94545-4339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-785-5000
Provider Business Practice Location Address Fax Number:
510-293-5606
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURDUSIS
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER OF INFORMATION SYSTEMS
Authorized Official Telephone Number:
510-785-5000

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 05D0599092 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0024010 . This is a "MEDICAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ81610Z . This is a "MEDICAL LAB PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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