Provider Demographics
NPI:1598738395
Name:WELLSPRING MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:WELLSPRING MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-551-9758
Mailing Address - Street 1:45 CASTRO ST
Mailing Address - Street 2:SUITE 423
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-1010
Mailing Address - Country:US
Mailing Address - Phone:415-551-9758
Mailing Address - Fax:415-437-5434
Practice Address - Street 1:45 CASTRO ST
Practice Address - Street 2:SUITE 423
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1010
Practice Address - Country:US
Practice Address - Phone:415-551-9758
Practice Address - Fax:415-437-5434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ16658ZMedicare ID - Type Unspecified