Provider Demographics
NPI:1598815110
Name:EXECUTIVE ENDOSCOPY, INC.
Entity Type:Organization
Organization Name:EXECUTIVE ENDOSCOPY, INC.
Other - Org Name:ENDOSCOPY CENTER OF SAN JOSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC DIRECTOR/SECRETARY OF ATF CO
Authorized Official - Prefix:DR
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:K
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-297-2314
Mailing Address - Street 1:2100 FOREST AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-297-2314
Mailing Address - Fax:408-297-2414
Practice Address - Street 1:2100 FOREST AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-297-2314
Practice Address - Fax:408-297-2414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000639261QA1903X
CA261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01553FMedicaid
CAZZZ23461ZMedicare PIN