Healthcare Provider Details

I. General information

NPI: 1720176225
Provider Name (Legal Business Name): PENINSULA SURGICAL SPECIALIST MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 EL CAMINO REAL SUITE 101
BURLINGAME CA
94010-3224
US

IV. Provider business mailing address

1720 EL CAMINO REAL SUITE 101
BURLINGAME CA
94010-3224
US

V. Phone/Fax

Practice location:
  • Phone: 650-652-0600
  • Fax:
Mailing address:
  • Phone: 650-652-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name: DR. DIRK BAUMANN
Title or Position: CFO
Credential: M.D.
Phone: 650-777-4064