Provider Demographics
NPI:1124561303
Name:SOUTH BAY ANGIOGRAPHY AND INTERVENTIONAL CENTER
Entity Type:Organization
Organization Name:SOUTH BAY ANGIOGRAPHY AND INTERVENTIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:POLYXENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOKINOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-376-3626
Mailing Address - Street 1:2255 S BASCOM AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7800
Mailing Address - Country:US
Mailing Address - Phone:408-376-3626
Mailing Address - Fax:408-871-2377
Practice Address - Street 1:2255 S BASCOM AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7800
Practice Address - Country:US
Practice Address - Phone:408-376-3626
Practice Address - Fax:408-871-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH73133Medicare UPIN
CAH71595Medicare UPIN
CAF95840Medicare UPIN