Provider Demographics
NPI:1528005055
Name:PACIFIC GYNECOLOGY & OBSTETRICS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PACIFIC GYNECOLOGY & OBSTETRICS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CERDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-923-3087
Mailing Address - Street 1:2100 WEBSTER ST
Mailing Address - Street 2:STE 319
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2373
Mailing Address - Country:US
Mailing Address - Phone:415-923-3123
Mailing Address - Fax:415-923-3132
Practice Address - Street 1:2100 WEBSTER ST
Practice Address - Street 2:STE 319
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2373
Practice Address - Country:US
Practice Address - Phone:415-923-3123
Practice Address - Fax:415-923-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11319207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18901ZMedicare ID - Type Unspecified