Provider Demographics
NPI:1659405165
Name:IMHOTEP ISSAQUENA MEDICAL GROUP
Entity Type:Organization
Organization Name:IMHOTEP ISSAQUENA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:ROUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-231-0955
Mailing Address - Street 1:2023 VALE RD
Mailing Address - Street 2:#211
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3834
Mailing Address - Country:US
Mailing Address - Phone:510-231-0955
Mailing Address - Fax:510-231-0482
Practice Address - Street 1:401 29TH ST
Practice Address - Street 2:#206
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3519
Practice Address - Country:US
Practice Address - Phone:510-231-0955
Practice Address - Fax:510-231-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33795261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G37795Medicaid
A47229Medicare UPIN
ZZZ90072ZMedicare PIN