Healthcare Provider Details

I. General information

NPI: 1619932209
Provider Name (Legal Business Name): PEDIATRIC SURGICAL ASSOCIATES OF THE EAST BAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 52ND ST SUITE 4100
OAKLAND CA
94609-1810
US

IV. Provider business mailing address

5528 PACHECO BLVD SUITE A
PACHECO CA
94553-5154
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3017
  • Fax: 510-428-3405
Mailing address:
  • Phone: 925-363-8170
  • Fax: 925-363-8178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: SUNGHOON KIM
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 510-428-3017