Provider Demographics
NPI:1629386867
Name:MARK BAZALGETTE, M.D., INC.
Entity Type:Organization
Organization Name:MARK BAZALGETTE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARDINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-461-3300
Mailing Address - Street 1:1300 S ELISEO DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2023
Mailing Address - Country:US
Mailing Address - Phone:415-461-3300
Mailing Address - Fax:415-461-2934
Practice Address - Street 1:1300 S ELISEO DR
Practice Address - Street 2:SUITE 203
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2023
Practice Address - Country:US
Practice Address - Phone:415-461-3300
Practice Address - Fax:415-461-2934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46290208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE25283Medicare UPIN