Provider Demographics
NPI:1326394974
Name:MISSION PEAK ORTHOPAEDIC MEDICAL GROUP INC.
Entity type:Organization
Organization Name:MISSION PEAK ORTHOPAEDIC MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINGAGOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:MEMULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-818-2011
Mailing Address - Street 1:39350 CIVIC CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2331
Mailing Address - Country:US
Mailing Address - Phone:510-797-3933
Mailing Address - Fax:510-797-5184
Practice Address - Street 1:27206 CALAROGA AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-4300
Practice Address - Country:US
Practice Address - Phone:510-300-9898
Practice Address - Fax:510-797-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ5427ZOtherBLUE SHIELD
CAZZZ16527ZMedicare PIN
CAG09341Medicare UPIN