1710907506 NPI number — JOHN MUIR PHYSICIAN NETWORK

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 1710907506 NPI number — JOHN MUIR PHYSICIAN NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN MUIR PHYSICIAN NETWORK
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:
1710907506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9017
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94598-0917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-952-2828
Provider Business Mailing Address Fax Number:
925-952-2850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 BROOKWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ORINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94563-3042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-254-9090
Provider Business Practice Location Address Fax Number:
925-254-4399
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SORENSON
Authorized Official First Name:
M
Authorized Official Middle Name:
KATHERINE
Authorized Official Title or Position:
VICE PRESIDENT PRACTICE ADM
Authorized Official Telephone Number:
925-952-2888

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR006875H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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