=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376631762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL SPRINGS SURGICAL ASSOCIATES, A MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 07/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 S SAN MATEO DR SUITE 302
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-685-2959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 S SAN MATEO DR SUITE 302
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-685-2959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JOHN J FENG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 650-685-2959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | G079786
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------