Provider Demographics
NPI:1477605517
Name:ERNEST A DERNBURG MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ERNEST A DERNBURG MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:A
Authorized Official - Last Name:DERNBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-567-5885
Mailing Address - Street 1:2456 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3106
Mailing Address - Country:US
Mailing Address - Phone:415-567-5885
Mailing Address - Fax:415-567-6309
Practice Address - Street 1:2456 BUSH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3106
Practice Address - Country:US
Practice Address - Phone:415-567-5885
Practice Address - Fax:415-567-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA198112084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A21894Medicare UPIN
00A198110Medicare ID - Type Unspecified