Provider Demographics
NPI:1073612537
Name:NEILL, MATHER HUMPHREY (MD)
Entity Type:Individual
Prefix:
First Name:MATHER
Middle Name:HUMPHREY
Last Name:NEILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:510-879-9100
Practice Address - Street 1:250 BON AIR ROAD
Practice Address - Street 2:
Practice Address - City:GREENBAE
Practice Address - State:CA
Practice Address - Zip Code:94902
Practice Address - Country:US
Practice Address - Phone:415-925-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31458207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G314580Medicaid
CAA44781Medicare UPIN
CA00G314580Medicaid