MEDICARE: MATEO MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1083809768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATEO MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2905 S EL CAMINO REAL
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-2730
Country	:	US
Telephone Number	:	650-570-2273
Fax Number	:	650-570-4266

Provider Business Practice Location Address
First Line	:	2905 S EL CAMINO REAL
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-2730
Country	:	US
Telephone Number	:	650-570-2273
Fax Number	:	650-570-4266

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. DENISE KUBICK
Credential	:
Telephone Number	:	650-685-9940

Provider Enumeration Date	:	09/06/2007
Last Update Date	:	09/06/2007

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