Provider Demographics
NPI:1639254501
Name:ACTIVE MEDICAL GROUP OF NORTHERN CA A PROFFESIONAL CORPORATION
Entity Type:Organization
Organization Name:ACTIVE MEDICAL GROUP OF NORTHERN CA A PROFFESIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-757-8900
Mailing Address - Street 1:1800 SULLIVAN AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2228
Mailing Address - Country:US
Mailing Address - Phone:650-757-8900
Mailing Address - Fax:
Practice Address - Street 1:1800 SULLIVAN AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2228
Practice Address - Country:US
Practice Address - Phone:650-757-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59110207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01434ZMedicare ID - Type Unspecified
CAA5342Medicare UPIN