Provider Demographics
NPI:1154464329
Name:PENINSULA ORTHOPEDIC ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PENINSULA ORTHOPEDIC ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-756-5630
Mailing Address - Street 1:1850 SULLIVAN AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2204
Mailing Address - Country:US
Mailing Address - Phone:650-756-5630
Mailing Address - Fax:650-994-1155
Practice Address - Street 1:1850 SULLIVAN AVE STE 330
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2204
Practice Address - Country:US
Practice Address - Phone:650-756-5630
Practice Address - Fax:650-994-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X
CA0208450001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053110Medicaid
CA0208450001Medicare NSC
CAGR0053110Medicaid