Healthcare Provider Details

I. General information

NPI: 1366185118
Provider Name (Legal Business Name): CHANNEL MEDICAL GROUP OF CALIFORNIA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 05/18/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 BAYWOOD DR FL 2
PETALUMA CA
94954-5510
US

IV. Provider business mailing address

4 E 27TH ST UNIT 20206
NEW YORK NY
10001-9410
US

V. Phone/Fax

Practice location:
  • Phone: 646-389-3451
  • Fax:
Mailing address:
  • Phone: 646-389-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: SABA HAQ
Title or Position: CEO
Credential: MD
Phone: 949-463-0650