Provider Demographics
NPI:1164710638
Name:BRIDGE FAMILY PRACTICE
Entity Type:Organization
Organization Name:BRIDGE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-595-1500
Mailing Address - Street 1:5900 SHATTUCK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1461
Mailing Address - Country:US
Mailing Address - Phone:510-595-1500
Mailing Address - Fax:510-595-1560
Practice Address - Street 1:5900 SHATTUCK AVE STE 101
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1461
Practice Address - Country:US
Practice Address - Phone:510-595-1500
Practice Address - Fax:510-595-1560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72340174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH34302Medicare UPIN
CADG850AMedicare PIN