Healthcare Provider Details

I. General information

NPI: 1689600314
Provider Name (Legal Business Name): EAST BAY AIDS CENTER MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SUMMIT ST 2ND FLOOR
OAKLAND CA
94609-3410
US

IV. Provider business mailing address

3100 SUMMIT ST, 2ND FLOOR
OAKLAND CA
94609
US

V. Phone/Fax

Practice location:
  • Phone: 510-869-8400
  • Fax: 510-869-8475
Mailing address:
  • Phone: 510-869-8488
  • Fax: 510-869-8478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. JEFFREY BURACK
Title or Position: PRESIDENT
Credential:
Phone: 510-869-8480