=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477785665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPEDIC INSTITUTE OF THE BAY AREA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2009
-----------------------------------------------------
Last Update Date | 12/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S SAN MATEO DR SUITE 424
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-262-4262
-----------------------------------------------------
Fax | 650-262-5862
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 S SAN MATEO DR SUITE 424
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-262-4262
-----------------------------------------------------
Fax | 650-262-5862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALBERTO A BOLANOS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 650-262-4262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | G84190
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------