Healthcare Provider Details

I. General information

NPI: 1366586356
Provider Name (Legal Business Name): SOUTH COUNTY PEDIATRIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 W TENNYSON RD
HAYWARD CA
94544-5236
US

IV. Provider business mailing address

5528 PACHECO BLVD STE A
PACHECO CA
94553-5126
US

V. Phone/Fax

Practice location:
  • Phone: 510-782-4470
  • Fax:
Mailing address:
  • Phone: 925-363-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TOMAS A MAGANA
Title or Position: DIRECTOR
Credential: M.D.
Phone: 510-782-4470