Healthcare Provider Details

I. General information

NPI: 1871731299
Provider Name (Legal Business Name): EAST BAY SPECIAL IMAGING MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 GRAND AVE SUITE 100
OAKLAND CA
94612-3725
US

IV. Provider business mailing address

PO BOX 1017
LAFAYETTE CA
94549-1017
US

V. Phone/Fax

Practice location:
  • Phone: 510-587-0650
  • Fax: 510-587-0649
Mailing address:
  • Phone: 510-587-0650
  • Fax: 510-587-0649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DOUGLAS H.L. CHIN
Title or Position: MANAGING PARTNER
Credential:
Phone: 510-451-6950