1619066511 NPI number — PENINSULA ULTRASOUND, MAMMOGRAPHY AND RADIOLOGY SERVICES MED GROUP INC

Table of content: (NPI 1619066511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619066511 NPI number — PENINSULA ULTRASOUND, MAMMOGRAPHY AND RADIOLOGY SERVICES MED GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA ULTRASOUND, MAMMOGRAPHY AND RADIOLOGY SERVICES MED 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:
PENINSULA DIAGNOSTIC IMAGING INC
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:
1619066511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 S SAN MATEO DR
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94401-3819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-343-1655
Provider Business Mailing Address Fax Number:
650-343-1686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 S SAN MATEO DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94401-3819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-343-1655
Provider Business Practice Location Address Fax Number:
650-343-1686
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLEINER
Authorized Official First Name:
BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
650-343-1655

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G46504 , 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: 1932326188 . This is a "NLAI NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1801835079 . This is a "SM NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1396878435 . This is a "BK NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1841297272 . This is a "MPASTO NPI" identifier . This identifiers is of the category "OTHER".




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