Provider Demographics
NPI:1144417148
Name:NORCAL UROLOGY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:NORCAL UROLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:DEVIVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-465-5800
Mailing Address - Street 1:3300 WEBSTER ST
Mailing Address - Street 2:SUITE 710
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3117
Mailing Address - Country:US
Mailing Address - Phone:510-465-5800
Mailing Address - Fax:510-839-8984
Practice Address - Street 1:501 S SHORE CTR W
Practice Address - Street 2:SUITE 103
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5762
Practice Address - Country:US
Practice Address - Phone:510-523-0273
Practice Address - Fax:510-523-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071771Medicaid
CAZZZ13419ZMedicare PIN