Provider Demographics
NPI:1619971165
Name:CALIFORNIA HEART EASTBAY MEDICAL GROUP
Entity Type:Organization
Organization Name:CALIFORNIA HEART EASTBAY MEDICAL GROUP
Other - Org Name:CALIFORNIA HEART EASTBAY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KLISIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-676-2600
Mailing Address - Street 1:2485 HIGH SCHOOL AVE
Mailing Address - Street 2:STE 312
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1819
Mailing Address - Country:US
Mailing Address - Phone:925-676-2600
Mailing Address - Fax:925-680-0212
Practice Address - Street 1:2485 HIGH SCHOOL AVE
Practice Address - Street 2:STE 312
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1819
Practice Address - Country:US
Practice Address - Phone:925-676-2600
Practice Address - Fax:925-680-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0050130Medicaid
CAZZZ29067ZMedicare PIN
CAA35354Medicare UPIN
CAA46100Medicare UPIN
CAA14263Medicare UPIN