1225164510 NPI number — NEUROLOGY MED ASSOCS CHO

Table of content: (NPI 1225164510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225164510 NPI number — NEUROLOGY MED ASSOCS CHO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGY MED ASSOCS CHO
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:
1225164510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3116 W MARCH LN
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95219-2369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-473-6555
Provider Business Mailing Address Fax Number:
209-473-6543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
747 52ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-428-3590
Provider Business Practice Location Address Fax Number:
510-601-3974
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BIRNBAUM
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
HEAD OF DEPT
Authorized Official Telephone Number:
510-428-3590

Provider Taxonomy Codes

  • Taxonomy code: 2080P0008X , with the licence number:  G49267 , 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: GR0094870 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G49267 . This is a "DR BIRNBAUM'S CA MD LIC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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