Provider Demographics
NPI:1154313237
Name:EAST BAY FAMILY PRACTICE MEDICAL GROUP INC
Entity type:Organization
Organization Name:EAST BAY FAMILY PRACTICE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT SHARE HOLDER
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:D'ANDREA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-645-9900
Mailing Address - Street 1:3100 TELEGRAPH AVE
Mailing Address - Street 2:STE 2109
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3210
Mailing Address - Country:US
Mailing Address - Phone:510-645-9900
Mailing Address - Fax:510-645-9919
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:STE 2109
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3210
Practice Address - Country:US
Practice Address - Phone:510-645-9900
Practice Address - Fax:510-645-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0003490Medicaid
CAGR0003490Medicaid