Healthcare Provider Details

I. General information

NPI: 1962423087
Provider Name (Legal Business Name): EAST BAY PULMONARY MEDICAL GROUP PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 VALE RD
SAN PABLO CA
94806-3808
US

IV. Provider business mailing address

2000 VALE RD
SAN PABLO CA
94806-3808
US

V. Phone/Fax

Practice location:
  • Phone: 510-222-5421
  • Fax: 510-222-5249
Mailing address:
  • Phone: 510-222-5421
  • Fax: 510-222-5249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number0000001075
License Number StateCA

VIII. Authorized Official

Name: MRS. COLLEEN TEJANO
Title or Position: OFFICE MANAGER
Credential:
Phone: 510-329-5421