Provider Demographics
NPI:1376575860
Name:SOUTH BAY ENDOSCOPY CENTER A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOUTH BAY ENDOSCOPY CENTER A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE/TECHNICAL COORDINATO
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:VIEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:408-595-7302
Mailing Address - Street 1:455 OCONNOR DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1633
Mailing Address - Country:US
Mailing Address - Phone:408-283-3715
Mailing Address - Fax:408-283-3718
Practice Address - Street 1:455 OCONNOR DR
Practice Address - Street 2:SUITE 340
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1633
Practice Address - Country:US
Practice Address - Phone:408-283-3715
Practice Address - Fax:408-283-3718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000447261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01394GMedicaid
CAZZZ13837ZMedicare ID - Type UnspecifiedASC