=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033928122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YIQI MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 OLD COUNTY RD STE 100
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-595-4829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 OLD COUNTY RD STE 100
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-788-9818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. AMY WANG
-----------------------------------------------------
Credential | DTCM
-----------------------------------------------------
Telephone | 650-788-9818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------