MEDICARE: BANCROFT PEDIATRIC MEDICAL GROUP

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	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A63066	OTHER		MIRIAM M RHEW MD LICENSE
2	A63180	OTHER		STEVE SANTUCCI MD LICENSE
3	20A10768	OTHER	CA	MICHELE TAMSE
4	A40292	OTHER		MARIA E BEAMER MD LICENSE
5	A102586	OTHER	CA	DARCY GRANT LICENSE
6	A60244	OTHER		LAURA DENENBERG MD LICENS
7	A69220	OTHER	CA	REI MASUI LICENSE
8	G80985	OTHER		LAURA GRUNBAUM MD LICENSE
9	A128385	OTHER	CA	JUDITH MILLSTEIN LICENSE

General Provider Information

NPI Number	:	1316903461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANCROFT PEDIATRIC MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1555 DOOLITTLE DR STE 180
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-2239
Country	:	US
Telephone Number	:	510-483-2600
Fax Number	:	510-483-2605

Provider Business Practice Location Address
First Line	:	1555 DOOLITTLE DR. 180
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577
Country	:	US
Telephone Number	:	510-483-2600
Fax Number	:	510-483-2605

Authorized Official
Title or Position	:	SENIOR PARTNER
Name	:	MIRIAN RHEW
Credential	:	MD
Telephone Number	:	510-483-2600

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	01/06/2016

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