Provider Demographics
NPI:1588879134
Name:MILLS PENINSULA MEDICAL GROUP
Entity type:Organization
Organization Name:MILLS PENINSULA MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:650-240-8011
Mailing Address - Street 1:50 S SAN MATEO DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3857
Mailing Address - Country:US
Mailing Address - Phone:650-696-9770
Mailing Address - Fax:650-375-1363
Practice Address - Street 1:50 S SAN MATEO DR
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3857
Practice Address - Country:US
Practice Address - Phone:650-696-9770
Practice Address - Fax:650-375-1363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ14902ZMedicare PIN