1568577997 NPI number — BAY AREA PEDIATRIC PULMONARY MEDICAL GROUP, INC

Table of content: (NPI 1568577997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568577997 NPI number — BAY AREA PEDIATRIC PULMONARY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY AREA PEDIATRIC PULMONARY MEDICAL GROUP, INC
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:
1568577997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
747 52ND ST
Provider Second Line Business Mailing Address:
SUITE 5409
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94609-1809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-428-3305
Provider Business Mailing Address Fax Number:
510-597-7154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
747 52ND ST
Provider Second Line Business Practice Location Address:
SUITE 5409
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:
510-428-3305
Provider Business Practice Location Address Fax Number:
510-597-7154
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARDY
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
510-428-3885

Provider Taxonomy Codes

  • Taxonomy code: 2080P0214X , 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: ZZZ64422Z . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0085560 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ60449Z . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ60448Z . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0085561 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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