Provider Demographics
NPI:1497760870
Name:BAY VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BAY VALLEY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF INFORMATION SYSTEMS
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDUSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-266-5401
Mailing Address - Street 1:27212 CALAROGA AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4339
Mailing Address - Country:US
Mailing Address - Phone:510-785-5000
Mailing Address - Fax:
Practice Address - Street 1:20126 STANTON AVE
Practice Address - Street 2:STE 201
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5271
Practice Address - Country:US
Practice Address - Phone:510-581-2559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0024011OtherMEDI-CAL
CA05D1079934OtherCLIA
CA05D0695762OtherCLIA