Healthcare Provider Details

I. General information

NPI: 1508854381
Provider Name (Legal Business Name): PULMONARY & CRITICAL CARE MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 CARRERA DR
MILL VALLEY CA
94941-3999
US

IV. Provider business mailing address

335 CARRERA DR
MILL VALLEY CA
94941-3999
US

V. Phone/Fax

Practice location:
  • Phone: 415-388-7210
  • Fax:
Mailing address:
  • Phone: 415-388-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA49947
License Number StateCA

VIII. Authorized Official

Name: MERRILL RALPH NISAM
Title or Position: PRESIDENT
Credential: MD
Phone: 415-924-1214