Healthcare Provider Details

I. General information

NPI: 1205928645
Provider Name (Legal Business Name): BAY AREA COMPREHENSIVE SPINE AND SPORTS MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 TELEGRAPH AVE STE 100
OAKLAND CA
94609-1710
US

IV. Provider business mailing address

5700 TELEGRAPH AVE STE 100
OAKLAND CA
94609-1710
US

V. Phone/Fax

Practice location:
  • Phone: 510-463-4700
  • Fax: 510-463-4722
Mailing address:
  • Phone: 510-463-4700
  • Fax: 510-463-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL KWANSUP PARK
Title or Position: PRESIDENT
Credential:
Phone: 510-463-4700