=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689600314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST BAY AIDS CENTER MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 12/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 SUMMIT ST 2ND FLOOR
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-869-8400
-----------------------------------------------------
Fax | 510-869-8475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 SUMMIT ST, 2ND FLOOR
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-869-8488
-----------------------------------------------------
Fax | 510-869-8478
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY BURACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-869-8480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------