Provider Demographics
NPI:1689858748
Name:EAST BAY SURGICAL ASSOCIATES, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EAST BAY SURGICAL ASSOCIATES, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:WT
Authorized Official - Last Name:POLIDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-757-0800
Mailing Address - Street 1:3903 LONE TREE WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6249
Mailing Address - Country:US
Mailing Address - Phone:925-757-0800
Mailing Address - Fax:925-757-2160
Practice Address - Street 1:3903 LONE TREE WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6249
Practice Address - Country:US
Practice Address - Phone:925-757-0800
Practice Address - Fax:925-757-2160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty