Provider Demographics
NPI:1578778197
Name:PENINSULA PEDIATRIC MED GRP INC
Entity Type:Organization
Organization Name:PENINSULA PEDIATRIC MED GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-342-4145
Mailing Address - Street 1:1720 EL CAMINO REAL
Mailing Address - Street 2:SUITE #205
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3224
Mailing Address - Country:US
Mailing Address - Phone:650-259-5050
Mailing Address - Fax:650-697-1317
Practice Address - Street 1:1720 EL CAMINO REAL
Practice Address - Street 2:SUITE #205
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3224
Practice Address - Country:US
Practice Address - Phone:650-259-5050
Practice Address - Fax:650-697-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty