Provider Demographics
NPI:1568636538
Name:BAY AREA PEDIATRIC MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BAY AREA PEDIATRIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:OCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-994-1800
Mailing Address - Street 1:1800 SULLIVAN AVE RM 202
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2222
Mailing Address - Country:US
Mailing Address - Phone:650-756-4200
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTHGATE AVE STE 213
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2231
Practice Address - Country:US
Practice Address - Phone:650-994-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081921Medicaid