Provider Demographics
NPI:1245565357
Name:UNIVERSITY HEALTHCARE ALLIANCE
Entity Type:Organization
Organization Name:UNIVERSITY HEALTHCARE ALLIANCE
Other - Org Name:MENLO MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-498-6631
Mailing Address - Street 1:321 MIDDLEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3500
Mailing Address - Country:US
Mailing Address - Phone:650-498-6500
Mailing Address - Fax:650-322-1321
Practice Address - Street 1:321 MIDDLEFIELD RD STE 260
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4010
Practice Address - Country:US
Practice Address - Phone:650-498-6500
Practice Address - Fax:650-322-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
CA207Q00000X, 207RG0100X, 207V00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00087MOtherMEDICARE GROUP NUMBER