Provider Demographics
NPI:1265680045
Name:LAUREL GROVE ACUTE HOSPITAL
Entity Type:Organization
Organization Name:LAUREL GROVE ACUTE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR - PFS
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:DERBEDROSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-869-6163
Mailing Address - Street 1:3012 SUMMIT ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3480
Mailing Address - Country:US
Mailing Address - Phone:510-869-6591
Mailing Address - Fax:510-869-6592
Practice Address - Street 1:19933 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4003
Practice Address - Country:US
Practice Address - Phone:510-537-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDEN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-04
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050095Medicare Oscar/Certification