Provider Demographics
NPI:1225351927
Name:BARRY CHANTRELLE MD INC
Entity Type:Organization
Organization Name:BARRY CHANTRELLE MD INC
Other - Org Name:BARRY CHANTRELLE MD INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANTRELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-451-8451
Mailing Address - Street 1:5801 CHRISTIE AVE
Mailing Address - Street 2:240
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1964
Mailing Address - Country:US
Mailing Address - Phone:510-451-8451
Mailing Address - Fax:510-594-1724
Practice Address - Street 1:5801 CHRISTIE AVE
Practice Address - Street 2:240
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1964
Practice Address - Country:US
Practice Address - Phone:510-451-8451
Practice Address - Fax:510-594-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35119174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G351190Medicaid
CA00G351190Medicaid
CA00G351190Medicare PIN