MEDICARE: NORTH EAST MEDICAL SERVICES

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	251X00000X	Supports Brokerage Agency
3	261QF0400X	Federally Qualified Health Center (FQHC)	220000118	CA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1518911304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH EAST MEDICAL SERVICES

Provider Business Mailing Address
First Line	:	2171 JUNIPERO SERRA BLVD STE 700
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94014-1982
Country	:	US
Telephone Number	:
Fax Number	:	415-433-4726

Provider Business Practice Location Address
First Line	:	1520 STOCKTON STREET
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94133-3354
Country	:	US
Telephone Number	:	415-391-9686
Fax Number	:	415-433-4726

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MR. EDDIE W CHAN
Credential	:	PHARM.D.
Telephone Number	:	415-391-9686

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	03/04/2022

211 CALLE MORSE
ARROYO, PR
00714-2350

Practice Phone: 787-839-3980
Practice Fax: 787-271-2515