Provider Demographics
NPI:1154700169
Name:ASSOCIATED SURGEONS OF HAYWARD
Entity type:Organization
Organization Name:ASSOCIATED SURGEONS OF HAYWARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:POTTORFF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:510-886-8844
Mailing Address - Street 1:175 N REDWOOD DR
Mailing Address - Street 2:SUITE 275
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1972
Mailing Address - Country:US
Mailing Address - Phone:415-331-8390
Mailing Address - Fax:415-331-8380
Practice Address - Street 1:19842 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4002
Practice Address - Country:US
Practice Address - Phone:510-886-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61064207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ47993ZMedicare PIN