Provider Demographics
NPI:1164484150
Name:MIDPENINSULA SURGICAL ASSOCIATES MEDICAL GROUP
Entity Type:Organization
Organization Name:MIDPENINSULA SURGICAL ASSOCIATES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:EISENSTAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-964-0600
Mailing Address - Street 1:2204 GRANT RD
Mailing Address - Street 2:STE 203
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-3877
Mailing Address - Country:US
Mailing Address - Phone:650-964-0600
Mailing Address - Fax:650-964-0991
Practice Address - Street 1:2204 GRANT RD
Practice Address - Street 2:STE 203
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3877
Practice Address - Country:US
Practice Address - Phone:650-964-0600
Practice Address - Fax:650-964-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ19414ZOtherPTAN
CAGR0048611Medicaid