Provider Demographics
NPI:1568520518
Name:PACIFIC FAMILY PRACTICE MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PACIFIC FAMILY PRACTICE MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-876-5762
Mailing Address - Street 1:1 SHRADER ST
Mailing Address - Street 2:578
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1016
Mailing Address - Country:US
Mailing Address - Phone:415-876-5762
Mailing Address - Fax:415-876-4538
Practice Address - Street 1:1 SHRADER ST
Practice Address - Street 2:578
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1016
Practice Address - Country:US
Practice Address - Phone:415-876-5762
Practice Address - Fax:415-876-4538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty