Provider Demographics
NPI:1093719817
Name:BAY AREA REHABILITATION MEDICAL GROUP
Entity Type:Organization
Organization Name:BAY AREA REHABILITATION MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:FECHTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-750-5761
Mailing Address - Street 1:2250 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1013
Mailing Address - Country:US
Mailing Address - Phone:415-750-5762
Mailing Address - Fax:
Practice Address - Street 1:2250 HAYES ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1013
Practice Address - Country:US
Practice Address - Phone:415-750-5762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP1128OtherGROUP MCRERR
CAGR0008970Medicaid
CAZZZ88920ZMedicare ID - Type UnspecifiedOFFICE PRACTICE
CAZZZ88920ZMedicare PIN