Healthcare Provider Details

I. General information

NPI: 1427109297
Provider Name (Legal Business Name): SOUTH EAST BAY PEDIATRIC MED GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2191 MOWRY AVE STE 600C
FREMONT CA
94538
US

IV. Provider business mailing address

2191 MOWRY AVE STE 600C
FREMONT CA
94538
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-4373
  • Fax: 510-792-3420
Mailing address:
  • Phone: 510-792-4373
  • Fax: 510-792-3420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEPHEN FRIEDKIN
Title or Position: CEO
Credential: MD CEO
Phone: 510-792-4373