Provider Demographics
NPI:1346520905
Name:PRIMA MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PRIMA MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CRISTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-884-1840
Mailing Address - Street 1:4 HAMILTON LNDG
Mailing Address - Street 2:SUITE100
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-8256
Mailing Address - Country:US
Mailing Address - Phone:415-884-1874
Mailing Address - Fax:415-883-7127
Practice Address - Street 1:5 BON AIR RD
Practice Address - Street 2:#101
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1143
Practice Address - Country:US
Practice Address - Phone:415-924-2515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMA MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-26
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72742208600000X
CAA111326208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03538ZOtherMEDICARE PTAN
CA222035382Medicare Oscar/Certification