MEDICARE: SAN RAMON ENDOSCOPY CENTER LLC

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	207RG0100X	Gastroenterology Physician
2	261QA1903X	Ambulatory Surgical Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZH0707Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1184635955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN RAMON ENDOSCOPY CENTER LLC

Provider Business Mailing Address
First Line	:	5801 NORRIS CANYON RD
Second Line	:	SUITE 220
City	:	SAN RAMON
State	:	CA
Zip	:	94583-5440
Country	:	US
Telephone Number	:	925-275-9966
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 NORRIS CANYON RD
Second Line	:	SUITE 220
City	:	SAN RAMON
State	:	CA
Zip	:	94583-5440
Country	:	US
Telephone Number	:	925-275-9966
Fax Number	:

Authorized Official
Title or Position	:	OFFICER / AUTHORIZED OFFICIAL
Name	:	ERIC BOON
Credential	:
Telephone Number	:	480-567-0269

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	06/20/2025

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