1316903461 NPI number — BANCROFT PEDIATRIC MEDICAL GROUP

Table of content: (NPI 1316903461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316903461 NPI number — BANCROFT PEDIATRIC MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANCROFT PEDIATRIC 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:
Provider Other Organization Name Type Code:
6
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:
1316903461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1555 DOOLITTLE DR STE 180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LEANDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94577-2239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-483-2600
Provider Business Mailing Address Fax Number:
510-483-2605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 DOOLITTLE DR. 180
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LEANDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-483-2600
Provider Business Practice Location Address Fax Number:
510-483-2605
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RHEW
Authorized Official First Name:
MIRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR PARTNER
Authorized Official Telephone Number:
510-483-2600

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A63066 . This is a "MIRIAM M RHEW MD LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: A63180 . This is a "STEVE SANTUCCI MD LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20A10768 . This is a "MICHELE TAMSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A40292 . This is a "MARIA E BEAMER MD LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: A102586 . This is a "DARCY GRANT LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A60244 . This is a "LAURA DENENBERG MD LICENS" identifier . This identifiers is of the category "OTHER".
  • Identifier: A69220 . This is a "REI MASUI LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G80985 . This is a "LAURA GRUNBAUM MD LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: A128385 . This is a "JUDITH MILLSTEIN LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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