Healthcare Provider Details

I. General information

NPI: 1548258106
Provider Name (Legal Business Name): PRIMA MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 08/13/2015
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

9 COMMERCIAL BLVD SUITE 200
NOVATO CA
94949-6118
US

V. Phone/Fax

Practice location:
  • Phone: 415-461-7800
  • Fax: 415-924-1375
Mailing address:
  • Phone: 415-842-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG88295
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG45217
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA72388
License Number StateCA

VIII. Authorized Official

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