Provider Demographics
NPI:1427109297
Name:SOUTH EAST BAY PEDIATRIC MED GROUP
Entity type:Organization
Organization Name:SOUTH EAST BAY PEDIATRIC MED GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD CEO
Authorized Official - Phone:510-792-4373
Mailing Address - Street 1:2191 MOWRY AVE
Mailing Address - Street 2:STE 600C
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538
Mailing Address - Country:US
Mailing Address - Phone:510-792-4373
Mailing Address - Fax:510-792-3420
Practice Address - Street 1:2191 MOWRY AVE
Practice Address - Street 2:STE 600C
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-792-4373
Practice Address - Fax:510-792-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty