Provider Demographics
NPI:1689600314
Name:EAST BAY AIDS CENTER MEDICAL GROUP INC
Entity Type:Organization
Organization Name:EAST BAY AIDS CENTER MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-869-8480
Mailing Address - Street 1:3100 SUMMIT ST, 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-869-8488
Mailing Address - Fax:510-869-8478
Practice Address - Street 1:3100 SUMMIT ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3410
Practice Address - Country:US
Practice Address - Phone:510-869-8400
Practice Address - Fax:510-869-8475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X, 207RI0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087700Medicaid
CAZZZ18446ZMedicare ID - Type Unspecified