Healthcare Provider Details

I. General information

NPI: 1699784405
Provider Name (Legal Business Name): CALIFORNIA SPINE DIAGNOSTICS MEDICAL GRP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 WEBSTER ST SUITE 518
SAN FRANCISCO CA
94115
US

IV. Provider business mailing address

2100 WEBSTER ST SUITE 518
SAN FRANCISCO CA
94115
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-7830
  • Fax: 415-600-7835
Mailing address:
  • Phone: 415-600-7830
  • Fax: 415-600-7835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG84882
License Number StateCA

VIII. Authorized Official

Name: MRS. LILY O'NEILL
Title or Position: ADMINISTRATOR
Credential:
Phone: 415-600-7831