Provider Demographics
NPI:1629550660
Name:UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Other - Org Name:DEPARTMENT OF ADDICTION MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CPG DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-476-8969
Mailing Address - Street 1:PO BOX 743749
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-3749
Mailing Address - Country:US
Mailing Address - Phone:415-514-3000
Mailing Address - Fax:415-502-8175
Practice Address - Street 1:1001 POTRERO AVE RM 5H22
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-502-0661
Practice Address - Fax:415-476-6202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty