Provider Demographics
NPI:1376671206
Name:PENINSULA MEDICAL GROUP
Entity Type:Organization
Organization Name:PENINSULA MEDICAL GROUP
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-692-8804
Mailing Address - Street 1:1720 EL CAMINO REAL
Mailing Address - Street 2:STE 145
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3224
Mailing Address - Country:US
Mailing Address - Phone:650-692-8804
Mailing Address - Fax:650-692-8805
Practice Address - Street 1:1720 EL CAMINO REAL
Practice Address - Street 2:STE 145
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3224
Practice Address - Country:US
Practice Address - Phone:650-692-8804
Practice Address - Fax:650-692-8805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA440070174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22551ZMedicare PIN