Provider Demographics
NPI:1639384274
Name:MILLS-PENINSULA MEDICAL GROUP
Entity Type:Organization
Organization Name:MILLS-PENINSULA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF MEDICAL MANAGEMENT PRIVACY OF
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN,ND
Authorized Official - Phone:650-240-8053
Mailing Address - Street 1:577 AIRPORT BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-2020
Mailing Address - Country:US
Mailing Address - Phone:650-240-8000
Mailing Address - Fax:650-240-0953
Practice Address - Street 1:577 AIRPORT BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-2020
Practice Address - Country:US
Practice Address - Phone:650-240-8000
Practice Address - Fax:650-240-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID