Provider Demographics
NPI:1194746057
Name:BERKELEY CARDIOVASCULAR MEDICAL GROUP
Entity type:Organization
Organization Name:BERKELEY CARDIOVASCULAR MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:EDELEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-549-4220
Mailing Address - Street 1:3300 WEBSTER ST STE 702
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3122
Mailing Address - Country:US
Mailing Address - Phone:510-549-4220
Mailing Address - Fax:510-433-0744
Practice Address - Street 1:3300 WEBSTER ST STE 702
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3122
Practice Address - Country:US
Practice Address - Phone:510-549-4220
Practice Address - Fax:510-433-0744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RC0000X, 207RC0001X
CA207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0025431Medicaid
CAGR0025433Medicaid
CAGR0025432Medicaid
CAZZZ25831ZMedicare PIN