Provider Demographics
NPI:1093979767
Name:ADRIENNE MCGRAEL SOUDERS MD INC
Entity Type:Organization
Organization Name:ADRIENNE MCGRAEL SOUDERS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCGRAEL SOUDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-375-7706
Mailing Address - Street 1:1 BAYWOOD AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-1537
Mailing Address - Country:US
Mailing Address - Phone:650-375-7706
Mailing Address - Fax:650-375-7899
Practice Address - Street 1:1 BAYWOOD AVE
Practice Address - Street 2:STE 5
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-1537
Practice Address - Country:US
Practice Address - Phone:650-375-7706
Practice Address - Fax:650-375-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG048839207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89886Medicare UPIN