Healthcare Provider Details

I. General information

NPI: 1407940224
Provider Name (Legal Business Name): GASTROENTEROLOGY ASSOCIATES OF THE EAST BAY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 WEBSTER STREET
BERKELEY CA
94705
US

IV. Provider business mailing address

2510 WEBSTER STREET
BERKELEY CA
94705
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-6555
  • Fax: 510-548-3761
Mailing address:
  • Phone: 510-548-6555
  • Fax: 510-548-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STACEY ATWOOD
Title or Position: BILLER
Credential:
Phone: 510-292-4528