1548258106 NPI number — PRIMA MEDICAL FOUNDATION

Table of content: (NPI 1548258106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548258106 NPI number — PRIMA MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMA MEDICAL FOUNDATION
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:
1548258106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
NOVATO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94949-6118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-842-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1260 S ELISEO DR
Provider Second Line Business Practice Location Address:
FLOOR 2
Provider Business Practice Location Address City Name:
GREENBRAE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94904-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-461-7800
Provider Business Practice Location Address Fax Number:
415-924-1375
Provider Enumeration Date:
10/07/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RUBEL
Authorized Official First Name:
JOANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. DIRECTOR OF PRACTICE OPERATIONS
Authorized Official Telephone Number:
415-842-5103

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  G88295 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: G45217 , registered in the state of CA ; 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: "N" .
  • Taxonomy code: 208D00000X , with the licence number: A72388 , 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)

  • Identifier: ZZZ03538Z . This is a "MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".