=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386938470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AXIOM MEDICAL GROUP, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2011
-----------------------------------------------------
Last Update Date | 06/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2058 12TH AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94116-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-759-8833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2058 12TH AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94116-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-759-8833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. REBECCA A GREEN
-----------------------------------------------------
Credential | N.D., L.AC.
-----------------------------------------------------
Telephone | 415-759-8833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC14320
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | ND419
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | C050117
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | C050117
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | C050117
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------