Provider Demographics
NPI:1407232085
Name:THE PERMANENTE MEDICAL GROUP
Entity Type:Organization
Organization Name:THE PERMANENTE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH MANAGER II
Authorized Official - Prefix:DR
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUKIENNIK-TAKAOKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:510-752-1075
Mailing Address - Street 1:275 WEST MACARTHUR BLVD.
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5693
Mailing Address - Country:US
Mailing Address - Phone:510-752-1075
Mailing Address - Fax:
Practice Address - Street 1:3900 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5693
Practice Address - Country:US
Practice Address - Phone:510-752-1075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 27420302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization