Healthcare Provider Details

I. General information

NPI: 1609350669
Provider Name (Legal Business Name): EDGAR CELIS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 NORTHGATE DR STE 460
SAN RAFAEL CA
94903-2542
US

IV. Provider business mailing address

1050 NORTHGATE DR STE 460
SAN RAFAEL CA
94903-2542
US

V. Phone/Fax

Practice location:
  • Phone: 415-306-7641
  • Fax: 415-526-3734
Mailing address:
  • Phone: 415-306-7641
  • Fax: 415-526-3734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDGAR CELIS
Title or Position: OWNER
Credential: MD
Phone: 617-372-3673