MEDICARE: SOUTH BAY ANGIOGRAPHY AND INTERVENTIONAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	2085R0202X	Diagnostic Radiology Physician	CA
2	2085R0204X	Vascular & Interventional Radiology Physician	CA
3	174400000X	Specialist	CA

General Provider Information

NPI Number	:	1124561303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BAY ANGIOGRAPHY AND INTERVENTIONAL CENTER

Provider Business Mailing Address
First Line	:	2255 S BASCOM AVE
Second Line	:	SUITE 200
City	:	CAMPBELL
State	:	CA
Zip	:	95008-7800
Country	:	US
Telephone Number	:	408-376-3626
Fax Number	:	408-871-2377

Provider Business Practice Location Address
First Line	:	2255 S BASCOM AVE
Second Line	:	SUITE 200
City	:	CAMPBELL
State	:	CA
Zip	:	95008-7800
Country	:	US
Telephone Number	:	408-376-3626
Fax Number	:	408-871-2377

Authorized Official
Title or Position	:	CEO
Name	:	DR. POLYXENE G KOKINOS
Credential	:	M.D.
Telephone Number	:	408-376-3626

Provider Enumeration Date	:	11/21/2016
Last Update Date	:	11/21/2016

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2255 S BASCOM AVE STE 200
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