Provider Demographics
NPI:1699784405
Name:CALIFORNIA SPINE DIAGNOSTICS MEDICAL GRP INC
Entity type:Organization
Organization Name:CALIFORNIA SPINE DIAGNOSTICS MEDICAL GRP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-600-7831
Mailing Address - Street 1:2100 WEBSTER ST
Mailing Address - Street 2:SUITE 518
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115
Mailing Address - Country:US
Mailing Address - Phone:415-600-7830
Mailing Address - Fax:415-600-7835
Practice Address - Street 1:2100 WEBSTER ST
Practice Address - Street 2:SUITE 518
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-600-7830
Practice Address - Fax:415-600-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84882208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
123360800OtherUS DEPT OF LABOR
P00111961OtherRAILROAD RETIREMENT
123360800OtherUS DEPT OF LABOR
A13759Medicare UPIN