MEDICARE: HEADQUARTERS MEDICAL GROUP PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207QS0010X	Sports Medicine (Family Medicine) Physician
2	2080S0010X	Pediatric Sports Medicine Physician
3	208100000X	Physical Medicine & Rehabilitation Physician
4	2081P0301X	Brain Injury Medicine (Physical Medicine & Rehabilitation) Physician
5	2084N0400X	Neurology Physician
6	2084P0301X	Brain Injury Medicine (Psychiatry & Neurology) Physician
7	225100000X	Physical Therapist
8	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1326919655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEADQUARTERS MEDICAL GROUP PA

Provider Business Mailing Address
First Line	:	2340 VAN NESS AVE APT 5
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-1848
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2340 VAN NESS AVE APT 5
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-1848
Country	:	US
Telephone Number	:	415-763-5790
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS ADMINISTRATOR
Name	:	LUCAS JOHNSTON
Credential	:
Telephone Number	:	973-270-3396

Provider Enumeration Date	:	09/17/2025
Last Update Date	:	09/17/2025

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Directions to “HEADQUARTERS MEDICAL GROUP PA ” Practice Location

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