MEDICARE: DR. DIANE GROTH MIMRAN MD

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	207P00000X	Emergency Medicine Physician	A91557	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A91557	OTHER	CA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1285670877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE GROTH MIMRAN MD

Provider Business Mailing Address
First Line	:	4009 TULIP WAY
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94582
Country	:	US
Telephone Number	:	925-964-1416
Fax Number	:

Provider Business Practice Location Address
First Line	:	6001 NORRIS CANYON RD
Second Line	:	SAN RAMON REGIONAL MEDICAL CENTER
City	:	SAN RAMON
State	:	CA
Zip	:	94583-5400
Country	:	US
Telephone Number	:	925-275-8282
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	07/08/2007

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