Provider Demographics
NPI:1306006879
Name:BAYVIEW GASTROENTEROLOGY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BAYVIEW GASTROENTEROLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADEMI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:831-662-9999
Mailing Address - Street 1:4145 CLARES ST
Mailing Address - Street 2:STE A
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2053
Mailing Address - Country:US
Mailing Address - Phone:831-662-9999
Mailing Address - Fax:831-662-9998
Practice Address - Street 1:4145 CLARES ST
Practice Address - Street 2:STE A
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2053
Practice Address - Country:US
Practice Address - Phone:831-662-9999
Practice Address - Fax:831-662-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7421207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH47780Medicare UPIN