Healthcare Provider Details

I. General information

NPI: 1184840555
Provider Name (Legal Business Name): BERKELEY ORTHOPAEDIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 COLBY ST SUITE 118
BERKELEY CA
94705-2059
US

IV. Provider business mailing address

3010 COLBY STREET SUITE 118
BERKELEY CA
94705
US

V. Phone/Fax

Practice location:
  • Phone: 510-845-3856
  • Fax: 510-845-1936
Mailing address:
  • Phone: 510-845-3856
  • Fax: 510-845-1936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: JOHN DEBENHAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-845-3856