Provider Demographics
NPI:1184840555
Name:BERKELEY ORTHOPAEDIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BERKELEY ORTHOPAEDIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBENHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-845-3856
Mailing Address - Street 1:3010 COLBY STREET
Mailing Address - Street 2:SUITE 118
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705
Mailing Address - Country:US
Mailing Address - Phone:510-845-3856
Mailing Address - Fax:510-845-1936
Practice Address - Street 1:3010 COLBY ST
Practice Address - Street 2:SUITE 118
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2059
Practice Address - Country:US
Practice Address - Phone:510-845-3856
Practice Address - Fax:510-845-1936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID NUMBER
CA=========OtherTAX ID NUMBER