Provider Demographics
NPI:1558546721
Name:GENERAL VASCULAR SURGERY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:GENERAL VASCULAR SURGERY MEDICAL GROUP, INC.
Other - Org Name:NONINVASIVE VASCULAR LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:O
Authorized Official - Last Name:GINGERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-347-4700
Mailing Address - Street 1:13851 E 14TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2631
Mailing Address - Country:US
Mailing Address - Phone:510-347-4700
Mailing Address - Fax:510-347-3712
Practice Address - Street 1:13855 E 14TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2611
Practice Address - Country:US
Practice Address - Phone:510-347-4700
Practice Address - Fax:510-347-4712
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENERAL VASCULAR SURGERY MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23370174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ15705ZMedicare PIN