Provider Demographics
NPI:1699820969
Name:EAST BAY ORTHOPAEDIC SPECIALISTS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EAST BAY ORTHOPAEDIC SPECIALISTS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-238-1468
Mailing Address - Street 1:350 30TH ST STE 530
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3426
Mailing Address - Country:US
Mailing Address - Phone:510-238-1468
Mailing Address - Fax:510-839-3796
Practice Address - Street 1:350 30TH ST STE 530
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3426
Practice Address - Country:US
Practice Address - Phone:510-238-1468
Practice Address - Fax:510-839-3796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38318207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G383180OtherMEDI-CAL
CA00G383180OtherMEDI-CAL
CAA47441Medicare UPIN