Provider Demographics
NPI:1174675417
Name:WASHINGTON TOWNSHIP MEDICAL GROUP
Entity Type:Organization
Organization Name:WASHINGTON TOWNSHIP MEDICAL GROUP
Other - Org Name:WASHINGTON TOWNSHIP MEDICAL GROUP, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-248-1000
Mailing Address - Street 1:39141 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5818
Mailing Address - Country:US
Mailing Address - Phone:510-248-1000
Mailing Address - Fax:510-608-6055
Practice Address - Street 1:38690 STIVERS ST
Practice Address - Street 2:SUITE A
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5279
Practice Address - Country:US
Practice Address - Phone:510-248-1040
Practice Address - Fax:510-797-7426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36600207Q00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104740Medicaid
CAZZZ69534ZOtherBLUE SHIELD 2ND LOCATION
CAZZZ69533ZOtherBLUE SHIELD GRP PIN
CAZZZ04658ZMedicare PIN