Provider Demographics
NPI:1144564899
Name:NORTH EAST MEDICAL SERVICES
Entity Type:Organization
Organization Name:NORTH EAST MEDICAL SERVICES
Other - Org Name:NORTH EAST MEDICAL SERVICES - CLEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:415-391-9686
Mailing Address - Street 1:1520 STOCKTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-3354
Mailing Address - Country:US
Mailing Address - Phone:415-391-9686
Mailing Address - Fax:415-433-4726
Practice Address - Street 1:1033 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-2112
Practice Address - Country:US
Practice Address - Phone:415-391-9686
Practice Address - Fax:415-433-4726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH EAST MEDICAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002073261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid