MEDICARE: SAN FRANCISCO-PENINSULA E N T ASSOCIATES A MEDICAL CORPORATION

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	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1992983480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN FRANCISCO-PENINSULA E N T ASSOCIATES A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	77 MORAGA WAY STE G
Second Line	:
City	:	ORINDA
State	:	CA
Zip	:	94563-3019
Country	:	US
Telephone Number	:	925-254-6710
Fax Number	:	925-254-6713

Provider Business Practice Location Address
First Line	:	77 MORAGA WAY STE G
Second Line	:
City	:	ORINDA
State	:	CA
Zip	:	94563-3019
Country	:	US
Telephone Number	:	925-254-6710
Fax Number	:	925-254-6713

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVEN THOMAS KMUCHA
Credential	:	MD JD
Telephone Number	:	925-254-6710

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	08/28/2020

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