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General NPI Number Information
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NPI Number | 1912186834
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Entity Type | Organization
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Legal Business Name | BAY AREA COMMITTED TO KIDS MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 10/27/2007
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Last Update Date | 12/29/2010
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Provider Practice Location Address
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Address Line | 3306 HERRIER ST
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City | OAKLAND
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State | CA
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Zip | 94602-4004
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Country | US
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Telephone | 510-336-0880
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Fax |
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Provider Business Mailing Address
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Address Line | 3306 HERRIER ST
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City | OAKLAND
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State | CA
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Zip | 94602-4004
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Country | US
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Telephone | 510-336-0880
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. JAMIE ELISE WALLACH
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Credential | M.D.
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Telephone | 510-336-0880
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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 | G79903
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License Number State | CA
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