Provider Demographics
NPI:1609056233
Name:NORTH BAY NEUROLOGIC MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:NORTH BAY NEUROLOGIC MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MENDIUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-464-0411
Mailing Address - Street 1:1000 S ELISEO DR STE 204
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2151
Mailing Address - Country:US
Mailing Address - Phone:415-464-0411
Mailing Address - Fax:
Practice Address - Street 1:1000 S ELISEO DR STE 204
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2151
Practice Address - Country:US
Practice Address - Phone:415-464-0411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG4032102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1235230384OtherNPI
CA1295765881OtherNPI
CA00G403210Medicaid
CA00G403210Medicaid