MEDICARE: PENINSULA ENDOSCOPY CENTER LLC

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	261QE0800X	Endoscopy Clinic/Center

General Provider Information

NPI Number	:	1548583651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENINSULA ENDOSCOPY CENTER LLC

Provider Business Mailing Address
First Line	:	1720 EL CAMINO REAL
Second Line	:	SUITE 100
City	:	BURLINGAME
State	:	CA
Zip	:	94010-3224
Country	:	US
Telephone Number	:	650-373-1970
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 EL CAMINO REAL
Second Line	:	SUITE 100
City	:	BURLINGAME
State	:	CA
Zip	:	94010-3224
Country	:	US
Telephone Number	:	650-373-1970
Fax Number	:

Authorized Official
Title or Position	:	CEO ADN AUTHORIZED OFFICIAL
Name	:	WILLIAM D DAVIS
Credential	:
Telephone Number	:	916-566-4770

Provider Enumeration Date	:	03/03/2010
Last Update Date	:	06/06/2016

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