Provider Demographics
NPI:1609986777
Name:EAST BAY CARDIAC SURGERY CENTER MEDICAL GROUP
Entity Type:Organization
Organization Name:EAST BAY CARDIAC SURGERY CENTER MEDICAL GROUP
Other - Org Name:IVERSON & STANTEN CARDIAC & THORACIC SURGERY MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNAID
Authorized Official - Middle Name:HAMEED
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-465-6600
Mailing Address - Street 1:3300 WEBSTER ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3117
Mailing Address - Country:US
Mailing Address - Phone:510-465-6600
Mailing Address - Fax:510-839-0806
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:SUITE 500
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-465-6600
Practice Address - Fax:510-839-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0060340Medicaid
CAZZZ03169ZOtherBLUE SHIELD GRP PROVIDER#
CAGR0060340Medicaid