Provider Demographics
NPI:1083857353
Name:BAY AREA RETINA ASSOCIATES, MEDICAL GROUP
Entity Type:Organization
Organization Name:BAY AREA RETINA ASSOCIATES, MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:MS
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:CRCS
Authorized Official - Phone:925-265-8324
Mailing Address - Street 1:365 LENNON LN STE 250
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-5915
Mailing Address - Country:US
Mailing Address - Phone:925-265-8324
Mailing Address - Fax:925-522-8658
Practice Address - Street 1:15051 HESPERIAN BLVD STE D
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-3536
Practice Address - Country:US
Practice Address - Phone:510-317-1111
Practice Address - Fax:510-317-1113
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAY AREA RETINA ASSOCIATES, MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-15
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030671Medicaid
CAGR0030670Medicaid
CAGR0030671Medicaid