MEDICARE: EAST BAY AREA QUALITY HEALTH CORPORATION

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	207RI0200X	Infectious Disease Physician	G73584	CA
2	207Q00000X	Family Medicine Physician	A64757	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CA209814	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1295182335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BAY AREA QUALITY HEALTH CORPORATION

Provider Business Mailing Address
First Line	:	400 29TH AVE
Second Line	:	SUITE 501
City	:	OAKLAND
State	:	CA
Zip	:	94601-2106
Country	:	US
Telephone Number	:	510-268-1800
Fax Number	:	510-268-1803

Provider Business Practice Location Address
First Line	:	400 29TH AVE
Second Line	:	SUITE 501
City	:	OAKLAND
State	:	CA
Zip	:	94601-2106
Country	:	US
Telephone Number	:	510-268-1800
Fax Number	:	510-268-1803

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANTHONY E. JONES
Credential	:	M.D.
Telephone Number	:	510-268-1800

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	09/22/2016

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