Provider Demographics
NPI:1962423087
Name:EAST BAY PULMONARY MEDICAL GROUP PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:EAST BAY PULMONARY MEDICAL GROUP PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TEJANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-329-5421
Mailing Address - Street 1:2000 VALE RD
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3808
Mailing Address - Country:US
Mailing Address - Phone:510-222-5421
Mailing Address - Fax:510-222-5249
Practice Address - Street 1:2000 VALE RD
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3808
Practice Address - Country:US
Practice Address - Phone:510-222-5421
Practice Address - Fax:510-222-5249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000001075225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0001530Medicaid
ZZZ94176ZMedicare PIN