Provider Demographics
NPI:1639282551
Name:MISSION PEAK ORTHOPAEDIC MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:MISSION PEAK ORTHOPAEDIC MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINGAGOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:MEMULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-818-2011
Mailing Address - Street 1:686 MOWRY AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4113
Mailing Address - Country:US
Mailing Address - Phone:510-797-3933
Mailing Address - Fax:510-797-5184
Practice Address - Street 1:5924 STONERIDGE DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-5400
Practice Address - Country:US
Practice Address - Phone:925-846-6200
Practice Address - Fax:510-797-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA657720207X00000X
CAA698780207X00000X
CAA81391208100000X, 2081P2900X
CAA95318208100000X
CAE4711213ES0103X
CAPA17256363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ5427ZOtherBLUE SHIELD
CAZZZ5427ZOtherBLUE SHIELD
CAI45989Medicare UPIN
CAG09341Medicare UPIN
CAZZZ16527ZMedicare PIN