=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609056233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH BAY NEUROLOGIC MEDICAL ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2007
-----------------------------------------------------
Last Update Date | 04/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 S ELISEO DR STE 204
-----------------------------------------------------
City | GREENBRAE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94904-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-464-0411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 S ELISEO DR STE 204
-----------------------------------------------------
City | GREENBRAE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94904-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-464-0411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN RICHARD MENDIUS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 415-464-0411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | G403210
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------