Healthcare Provider Details

I. General information

NPI: 1164697090
Provider Name (Legal Business Name): BAY AREA PEDIATRIC MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SOUTHGATE AVE STE 213
DALY CITY CA
94015-2231
US

IV. Provider business mailing address

123 S SAN MATEO DR
SAN MATEO CA
94401-3804
US

V. Phone/Fax

Practice location:
  • Phone: 650-994-1800
  • Fax: 650-994-1888
Mailing address:
  • Phone: 650-343-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DONNA OCONNELL
Title or Position: MANAGER BUSINESS OFFICE
Credential:
Phone: 650-994-1800