Healthcare Provider Details

I. General information

NPI: 1417025545
Provider Name (Legal Business Name): PACIFIC WOMENS OBSTETRICS & GYNECOLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 CALIFORNIA ST 316
SAN FRANCISCO CA
94118-1522
US

IV. Provider business mailing address

3838 CALIFORNIA ST 316
SAN FRANCISCO CA
94118-1522
US

V. Phone/Fax

Practice location:
  • Phone: 415-379-9600
  • Fax: 415-379-9823
Mailing address:
  • Phone: 415-379-9600
  • Fax: 415-379-9823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: LAURIE RAE GREEN
Title or Position: MANAGING PHYSICIAN
Credential: M.D.
Phone: 415-379-9600