Provider Demographics
NPI:1477666352
Name:PEDIATRIC MEDICAL GROUP OF SAN FRANCISCO INC
Entity Type:Organization
Organization Name:PEDIATRIC MEDICAL GROUP OF SAN FRANCISCO INC
Other - Org Name:THE PEDIATRIC MEDICAL GROUP OF SAN FRANCISCO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:SANTOS
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-242-5433
Mailing Address - Street 1:901 CAMPUS DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4900
Mailing Address - Country:US
Mailing Address - Phone:415-242-5433
Mailing Address - Fax:415-242-8904
Practice Address - Street 1:901 CAMPUS DR
Practice Address - Street 2:SUITE 207
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4900
Practice Address - Country:US
Practice Address - Phone:415-242-5433
Practice Address - Fax:415-242-8904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3896319173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty