Healthcare Provider Details

I. General information

NPI: 1790990307
Provider Name (Legal Business Name): PENINSULA PEDIATRIC MED GRP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 S SAN MATEO DR SUITE #180
SAN MATEO CA
94401-3857
US

IV. Provider business mailing address

1720 EL CAMINO REAL SUITE #230
BURLINGAME CA
94010-3224
US

V. Phone/Fax

Practice location:
  • Phone: 650-342-4141
  • Fax: 650-342-2070
Mailing address:
  • Phone: 650-259-1545
  • Fax: 650-259-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. ALBERT R KASUGA
Title or Position: PRESIDENT
Credential: MD
Phone: 650-259-5050