Provider Demographics
NPI:1609157734
Name:PRIMA MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PRIMA MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR OF PRATICE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-842-5103
Mailing Address - Street 1:4 HAMILTON LNDG
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-8256
Mailing Address - Country:US
Mailing Address - Phone:415-884-1840
Mailing Address - Fax:415-884-3510
Practice Address - Street 1:100 A DRAKES LANDING RD
Practice Address - Street 2:SUITE 225
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-3119
Practice Address - Country:US
Practice Address - Phone:415-461-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMA MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-02
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
CAA65187208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03538ZOtherMEDICARE PTAN
CAZZZ03538ZOtherMEDICARE PTAN