MEDICARE: FAMILY PRACTICE MEDICAL GROUP OF OAKLAND

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ45714Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1649234865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PRACTICE MEDICAL GROUP OF OAKLAND

Provider Business Mailing Address
First Line	:	350 30TH ST
Second Line	:	SUITE 407
City	:	OAKLAND
State	:	CA
Zip	:	94609-3425
Country	:	US
Telephone Number	:	510-419-0230
Fax Number	:	510-419-0440

Provider Business Practice Location Address
First Line	:	350 30TH ST
Second Line	:	SUITE 407
City	:	OAKLAND
State	:	CA
Zip	:	94609-3425
Country	:	US
Telephone Number	:	510-419-0230
Fax Number	:	510-419-0440

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CAREEN RENEE WHITLEY
Credential	:	MD
Telephone Number	:	510-419-0230

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	05/26/2011

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