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General NPI Number Information
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NPI Number | 1376671206
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Entity Type | Organization
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Legal Business Name | PENINSULA MEDICAL GROUP
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 03/10/2008
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Provider Practice Location Address
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Address Line | 1720 EL CAMINO REAL STE 145
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City | BURLINGAME
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State | CA
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Zip | 94010-3224
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Country | US
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Telephone | 650-692-8804
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Fax | 650-692-8805
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Provider Business Mailing Address
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Address Line | 1720 EL CAMINO REAL STE 145
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City | BURLINGAME
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State | CA
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Zip | 94010-3224
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Country | US
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Telephone | 650-692-8804
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Fax | 650-692-8805
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. SPENCER TIMOTHY LOWE
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Credential | M.D.
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Telephone | 650-692-8804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A440070
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License Number State | CA
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