Healthcare Provider Details

I. General information

NPI: 1689858748
Provider Name (Legal Business Name): EAST BAY SURGICAL ASSOCIATES, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 LONE TREE WAY SUITE 210
ANTIOCH CA
94509-6249
US

IV. Provider business mailing address

3903 LONE TREE WAY SUITE 210
ANTIOCH CA
94509-6249
US

V. Phone/Fax

Practice location:
  • Phone: 925-757-0800
  • Fax: 925-757-2160
Mailing address:
  • Phone: 925-757-0800
  • Fax: 925-757-2160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILLIP W.T. POLIDO
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 925-757-0800