Provider Demographics
NPI:1619932209
Name:PEDIATRIC SURGICAL ASSOCIATES OF THE EAST BAY
Entity Type:Organization
Organization Name:PEDIATRIC SURGICAL ASSOCIATES OF THE EAST BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUNGHOON
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-428-3017
Mailing Address - Street 1:5528 PACHECO BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PACHECO
Mailing Address - State:CA
Mailing Address - Zip Code:94553-5154
Mailing Address - Country:US
Mailing Address - Phone:925-363-8170
Mailing Address - Fax:925-363-8178
Practice Address - Street 1:744 52ND ST
Practice Address - Street 2:SUITE 4100
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1810
Practice Address - Country:US
Practice Address - Phone:510-428-3017
Practice Address - Fax:510-428-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086800Medicaid