Provider Demographics
NPI:1083057798
Name:GENERAL K HILLIARD, M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GENERAL K HILLIARD, M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:VISCOVICH-BUSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-961-8920
Mailing Address - Street 1:13847 E 14TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2626
Mailing Address - Country:US
Mailing Address - Phone:510-352-5325
Mailing Address - Fax:510-351-7446
Practice Address - Street 1:13847 E 14TH ST STE 203
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2626
Practice Address - Country:US
Practice Address - Phone:510-352-5325
Practice Address - Fax:510-351-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C32269174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C32269Medicare PIN