Healthcare Provider Details

I. General information

NPI: 1376844753
Provider Name (Legal Business Name): CENTER FOR COLORECTAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SUTTER ST SUITE 1019
SAN FRANCISCO CA
94108-4206
US

IV. Provider business mailing address

450 SUTTER ST SUITE 1019
SAN FRANCISCO CA
94108-4206
US

V. Phone/Fax

Practice location:
  • Phone: 415-765-0413
  • Fax: 415-765-1758
Mailing address:
  • Phone: 415-765-0413
  • Fax: 415-765-1758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberG85165
License Number StateCA

VIII. Authorized Official

Name: MYRIAM HEFFERNAN
Title or Position: MANAGER
Credential:
Phone: 415-765-0413