MEDICARE: PRIMA MEDICAL FOUNDATION

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	207X00000X	Orthopaedic Surgery Physician	G88678	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ03538Z	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1649551201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMA MEDICAL FOUNDATION

Provider Business Mailing Address
First Line	:	4 HAMILTON LNDG
Second Line	:	SUITE 100
City	:	NOVATO
State	:	CA
Zip	:	94949-8256
Country	:	US
Telephone Number	:	415-884-1840
Fax Number	:	415-884-3510

Provider Business Practice Location Address
First Line	:	651 1ST ST W
Second Line	:	SUITE K
City	:	SONOMA
State	:	CA
Zip	:	95476-7045
Country	:	US
Telephone Number	:	707-938-3870
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOEL A. CRISTE
Credential	:
Telephone Number	:	415-884-1840

Provider Enumeration Date	:	09/08/2011
Last Update Date	:	07/24/2012

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Directions to “PRIMA MEDICAL FOUNDATION ” Practice Location

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