Provider Demographics
NPI:1619066511
Name:PENINSULA ULTRASOUND, MAMMOGRAPHY AND RADIOLOGY SERVICES MED GROUP INC
Entity Type:Organization
Organization Name:PENINSULA ULTRASOUND, MAMMOGRAPHY AND RADIOLOGY SERVICES MED GROUP INC
Other - Org Name:PENINSULA DIAGNOSTIC IMAGING INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-343-1655
Mailing Address - Street 1:101 S SAN MATEO DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3819
Mailing Address - Country:US
Mailing Address - Phone:650-343-1655
Mailing Address - Fax:650-343-1686
Practice Address - Street 1:101 S SAN MATEO DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3819
Practice Address - Country:US
Practice Address - Phone:650-343-1655
Practice Address - Fax:650-343-1686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932326188OtherNLAI NPI
1801835079OtherSM NPI
1396878435OtherBK NPI
1841297272OtherMPASTO NPI