Provider Demographics
NPI:1396949822
Name:EVERGREEN HILLS MEDICAL GROUP
Entity type:Organization
Organization Name:EVERGREEN HILLS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SIAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-223-7771
Mailing Address - Street 1:2690 S WHITE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2076
Mailing Address - Country:US
Mailing Address - Phone:408-223-7771
Mailing Address - Fax:408-223-7779
Practice Address - Street 1:2690 S WHITE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2076
Practice Address - Country:US
Practice Address - Phone:408-223-7771
Practice Address - Fax:408-223-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA73641OtherSTATE LICENSE NUMBER
CAG69952OtherSTATE LICENSE NUMBER
CAA67291OtherSTATE LICENSE NUMBER
CAG73395OtherSTATE LICENSE NUMBER
CAH07085Medicare UPIN
CAF77203Medicare UPIN
CAA73641OtherSTATE LICENSE NUMBER
CAA67291OtherSTATE LICENSE NUMBER
CAZZZ24636ZMedicare ID - Type Unspecified