Healthcare Provider Details

I. General information

NPI: 1043494651
Provider Name (Legal Business Name): ASSOCIATED INTERNAL MEDICINE MED GRP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BAY PL
OAKLAND CA
94610-4448
US

IV. Provider business mailing address

350 30TH ST SUITE 320
OAKLAND CA
94609-3424
US

V. Phone/Fax

Practice location:
  • Phone: 510-891-8519
  • Fax: 510-891-8518
Mailing address:
  • Phone: 510-465-6700
  • Fax: 510-465-7765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG84227
License Number StateCA

VIII. Authorized Official

Name: DR. DEAN J. NICKLES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-465-6700