MEDICARE: BAY PEDIATRIC DEVELOPMENT

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency	MFC32136	CA
2	251S00000X	Community/Behavioral Health Agency	MFC32136	CA

General Provider Information

NPI Number	:	1184085979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAY PEDIATRIC DEVELOPMENT

Provider Business Mailing Address
First Line	:	111 DEERWOOD RD STE 395
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1530
Country	:	US
Telephone Number	:	415-895-0207
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 DEERWOOD RD STE 395
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1530
Country	:	US
Telephone Number	:	415-895-0207
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	ANAMERCEDES YEGANEH
Credential	:
Telephone Number	:	415-579-2731

Provider Enumeration Date	:	03/08/2016
Last Update Date	:	03/08/2016

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