MEDICARE: HLY MEDICAL GROUP CA, P.A

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1558121905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HLY MEDICAL GROUP CA, P.A

Provider Business Mailing Address
First Line	:	2215 S EL CAMINO REAL STE 206
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-1898
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 S EL CAMINO REAL STE 206
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-1898
Country	:	US
Telephone Number	:	415-413-8833
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VANESSA NILES
Credential	:	MD
Telephone Number	:	415-413-8833

Provider Enumeration Date	:	03/21/2024
Last Update Date	:	03/21/2024

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