Provider Demographics
NPI:1477598894
Name:EAST BAY PHYSICIANS MEDICAL GROUP
Entity Type:Organization
Organization Name:EAST BAY PHYSICIANS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-254-2008
Mailing Address - Street 1:PO BOX 254869
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-4869
Mailing Address - Country:US
Mailing Address - Phone:916-854-6634
Mailing Address - Fax:916-854-6739
Practice Address - Street 1:89 DAVIS RD
Practice Address - Street 2:SUITE 220
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-3031
Practice Address - Country:US
Practice Address - Phone:925-254-2008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Not Answered207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101862Medicaid
CAGR0101867Medicaid
CAGR0101872Medicaid
CAGR0101874Medicaid
CAGR0101870Medicaid
CAGR0101863Medicaid
CAGR0101866Medicaid
CAGR0101873Medicaid
CAGR0101860Medicaid
CAGR0101868Medicaid
CAGR0101871Medicaid
CAGR0101861Medicaid
CAGR0101864Medicaid
CAGR0101865Medicaid
CAGR0101869Medicaid
CAGR0101875Medicaid
CAGR0101876Medicaid