=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124202296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDISINA SA FAMILIA, PA, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2007
-----------------------------------------------------
Last Update Date | 10/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 SULLIVAN AVE STE 510
-----------------------------------------------------
City | DALY CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94015-2230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-580-6479
-----------------------------------------------------
Fax | 650-735-5580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5607
-----------------------------------------------------
City | SOUTH SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94083-5607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-580-6479
-----------------------------------------------------
Fax | 650-735-5580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. TERESITA YEE DEGAMO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 650-580-6479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | C50610
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------