1619971165 NPI number — CALIFORNIA HEART EASTBAY MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619971165 NPI number — CALIFORNIA HEART EASTBAY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALIFORNIA HEART EASTBAY MEDICAL GROUP
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:
CALIFORNIA HEART EASTBAY MEDICAL GROUP
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:
1619971165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2485 HIGH SCHOOL AVE
Provider Second Line Business Mailing Address:
STE 312
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94520-1819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-676-2600
Provider Business Mailing Address Fax Number:
925-680-0212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2485 HIGH SCHOOL AVE
Provider Second Line Business Practice Location Address:
STE 312
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94520-1819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-676-2600
Provider Business Practice Location Address Fax Number:
925-680-0212
Provider Enumeration Date:
06/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KLISIEWICZ
Authorized Official First Name:
JACQUELYN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
925-676-2600

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0050130 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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