Provider Demographics
NPI:1326585449
Name:GOLDEN GATE UROLOGY INC
Entity Type:Organization
Organization Name:GOLDEN GATE UROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, FINANCE AND ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BETANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-543-2812
Mailing Address - Street 1:2999 REGENT ST
Mailing Address - Street 2:SUITE 612
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2190
Mailing Address - Country:US
Mailing Address - Phone:510-495-3332
Mailing Address - Fax:510-848-8224
Practice Address - Street 1:2999 REGENT ST
Practice Address - Street 2:SUITE 612 & 626
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2190
Practice Address - Country:US
Practice Address - Phone:510-495-3332
Practice Address - Fax:510-848-8224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71078332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACC893AMedicare PIN