Provider Demographics
NPI:1386938470
Name:AXIOM MEDICAL GROUP, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:AXIOM MEDICAL GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:415-759-8833
Mailing Address - Street 1:2058 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1306
Mailing Address - Country:US
Mailing Address - Phone:415-759-8833
Mailing Address - Fax:
Practice Address - Street 1:2058 12TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-1306
Practice Address - Country:US
Practice Address - Phone:415-759-8833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14320171100000X
CAND419175F00000X
CAC050117207R00000X, 207RC0000X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty