Provider Demographics
NPI:1063487122
Name:UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Other - Org Name:UCSF SFGH MEDICAL GROUP DEPT OF RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR UCSF SFGH CPG BUSINESS
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-476-8969
Mailing Address - Street 1:PO BOX 743749
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7464
Mailing Address - Country:US
Mailing Address - Phone:415-514-3000
Mailing Address - Fax:415-502-8175
Practice Address - Street 1:1001 POTRERO AVENUE BLDG 5, 1ST FL
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-5871
Practice Address - Fax:628-206-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0028520Medicaid
CAZZZ14869ZMedicare PIN