=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891930673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST BAY RHEUMATOLOGY MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2008
-----------------------------------------------------
Last Update Date | 02/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13851 E 14TH ST STE 301
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94578-2630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-357-1303
-----------------------------------------------------
Fax | 510-357-5463
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13851 E 14TH ST STE 301
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94578-2630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-357-1303
-----------------------------------------------------
Fax | 510-357-5463
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. CLARK MICHAEL NEUWELT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 510-357-1303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G38264
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------