MEDICARE: EAST BAY HEALTH MEDICAL GROUP SPC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1780466201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BAY HEALTH MEDICAL GROUP SPC

Provider Business Mailing Address
First Line	:	911 MORAGA RD STE 101
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-4591
Country	:	US
Telephone Number	:	925-444-7073
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 MORAGA RD STE 101
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-4591
Country	:	US
Telephone Number	:	925-444-7073
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. NAOMI BRECKON
Credential	:	MD
Telephone Number	:	925-744-7600

Provider Enumeration Date	:	10/18/2023
Last Update Date	:	10/18/2023

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