Healthcare Provider Details

I. General information

NPI: 1396909735
Provider Name (Legal Business Name): PRIMA MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 S. ELISEO DR FLOOR 2
GREENBRAE CA
94904-2009
US

IV. Provider business mailing address

4 HAMILTON LANDING SUITE 100
NOVATO CA
94949
US

V. Phone/Fax

Practice location:
  • Phone: 415-924-1214
  • Fax:
Mailing address:
  • Phone: 415-884-1840
  • Fax: 415-884-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG55637
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA65187
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA42149
License Number StateCA

VIII. Authorized Official

Name: JOANNA RUBEL
Title or Position: SR. DIRECTOR OF PRACTICE OPERATIONS
Credential:
Phone: 415-842-5103