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NPI Code Detail

MEDICARE: BERKELEY PEDIATRIC MEDICAL GROUP, INC.

MEDICARE: BERKELEY PEDIATRIC 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
1208000000XPediatrics Physician

General Provider Information

NPI Number : 1407873425
Entity Type Code : Organization
Provider Name (Legal Business Name) : BERKELEY PEDIATRIC MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 1650 WALNUT ST
Second Line :
City : BERKELEY
State : CA
Zip : 94709-1606
Country : US
Telephone Number : 510-848-2566
Fax Number :
Provider Business Practice Location Address
First Line : 1650 WALNUT ST
Second Line :
City : BERKELEY
State : CA
Zip : 94709-1606
Country : US
Telephone Number : 510-848-2566
Fax Number :
Authorized Official
Title or Position : PRACTICE ADMINISTRATOR
Name : EYDIE TALAVERA
Credential :
Telephone Number : 510-848-2566
Provider Enumeration Date : 07/16/2006
Last Update Date : 08/22/2020

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