Provider Demographics
NPI:1639203672
Name:EAST BAY SURGICAL ASSOCIATES MEDICAL GROUP
Entity Type:Organization
Organization Name:EAST BAY SURGICAL ASSOCIATES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERKT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-724-5714
Mailing Address - Street 1:1430 TARA HILLS DR
Mailing Address - Street 2:STE D
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2580
Mailing Address - Country:US
Mailing Address - Phone:510-724-5714
Mailing Address - Fax:
Practice Address - Street 1:1430 TARA HILLS DR
Practice Address - Street 2:STE D
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2580
Practice Address - Country:US
Practice Address - Phone:510-724-5714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0058731Medicaid
CAA23275Medicare UPIN
CAGR0058731Medicaid