Provider Demographics
NPI:1316903461
Name:BANCROFT PEDIATRIC MEDICAL GROUP
Entity type:Organization
Organization Name:BANCROFT PEDIATRIC MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-483-2600
Mailing Address - Street 1:1555 DOOLITTLE DR STE 180
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2239
Mailing Address - Country:US
Mailing Address - Phone:510-483-2600
Mailing Address - Fax:510-483-2605
Practice Address - Street 1:1555 DOOLITTLE DR. 180
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577
Practice Address - Country:US
Practice Address - Phone:510-483-2600
Practice Address - Fax:510-483-2605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A63066OtherMIRIAM M RHEW MD LICENSE
A63180OtherSTEVE SANTUCCI MD LICENSE
CA20A10768OtherMICHELE TAMSE
A40292OtherMARIA E BEAMER MD LICENSE
CAA102586OtherDARCY GRANT LICENSE
A60244OtherLAURA DENENBERG MD LICENS
CAA69220OtherREI MASUI LICENSE
G80985OtherLAURA GRUNBAUM MD LICENSE
CAA128385OtherJUDITH MILLSTEIN LICENSE
I46484Medicare UPIN
G08630Medicare UPIN
A86342Medicare UPIN
CAA102586OtherDARCY GRANT LICENSE
G80985OtherLAURA GRUNBAUM MD LICENSE
A60244OtherLAURA DENENBERG MD LICENS
A40292OtherMARIA E BEAMER MD LICENSE