MEDICARE: EAST BAY RETINA CONSULTANTS A MEDICAL GROUP, INC.

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	207W00000X	Ophthalmology Physician	A44312	CA

General Provider Information

NPI Number	:	1326031907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BAY RETINA CONSULTANTS A MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	3300 TELEGRAPH AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94609-3028
Country	:	US
Telephone Number	:	510-444-1600
Fax Number	:	510-444-5117

Provider Business Practice Location Address
First Line	:	3300 WEBSTER ST
Second Line	:	SUITE 1110
City	:	OAKLAND
State	:	CA
Zip	:	94609-3117
Country	:	US
Telephone Number	:	510-444-1600
Fax Number	:	510-444-5117

Authorized Official
Title or Position	:	CORPORATE VICE PRESIDENT
Name	:	SOON T LEE
Credential	:	M.D.
Telephone Number	:	510-444-1600

Provider Enumeration Date	:	08/29/2005
Last Update Date	:	02/29/2016

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