=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699784405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA SPINE DIAGNOSTICS MEDICAL GRP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 01/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 WEBSTER ST SUITE 518
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-600-7830
-----------------------------------------------------
Fax | 415-600-7835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 WEBSTER ST SUITE 518
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-600-7830
-----------------------------------------------------
Fax | 415-600-7835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. LILY O'NEILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-600-7831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | G84882
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------