Healthcare Provider Details

I. General information

NPI: 1427008135
Provider Name (Legal Business Name): WALL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 GRAND AVE
SOUTH SAN FRANCISCO CA
94080-3635
US

IV. Provider business mailing address

2001 UNION ST SUITE 300
SAN FRANCISCO CA
94123-4114
US

V. Phone/Fax

Practice location:
  • Phone: 650-636-1286
  • Fax: 650-588-4164
Mailing address:
  • Phone: 650-636-1291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberZZZ96273Z
License Number StateCA

VIII. Authorized Official

Name: CATHERINE BROOKS
Title or Position: OFFICE MANAGER
Credential:
Phone: 650-636-1291