1497136931 NPI number — LINCOLN

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 1497136931 NPI number — LINCOLN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LINCOLN
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:
1497136931
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1266 14TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94607-2205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-273-4700
Provider Business Mailing Address Fax Number:
510-530-8083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 MARKET 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:
94607-3330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-874-7774
Provider Business Practice Location Address Fax Number:
510-874-7742
Provider Enumeration Date:
06/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BECWAR
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
STAULCUP
Authorized Official Title or Position:
CHIEF PROGRAM OFFICER
Authorized Official Telephone Number:
510-273-4700

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000054BM . This is a "MEDI-CAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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