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General NPI Number Information
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NPI Number | 1861591752
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Entity Type | Organization
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Legal Business Name | INTERNATIONAL PEDIATRIC MEDICAL GROUP INC
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 600 INTERNATIONAL BLVD #102
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City | OAKLAND
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State | CA
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Zip | 94606
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Country | US
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Telephone | 510-208-3540
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Fax | 510-208-3553
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Provider Business Mailing Address
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Address Line | 600 INTERNATIONAL BLVD #102
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City | OAKLAND
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State | CA
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Zip | 94606
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Country | US
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Telephone | 510-208-3540
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Fax | 510-208-3553
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Authorized Official
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Title or Position | MD
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Name | AN TAN PHAM
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Credential | MD
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Telephone | 510-208-3540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A67904
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License Number State | CA
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