Provider Demographics
NPI:1730463258
Name:PRIMA MEDICAL GROUP-TERRA LINDA
Entity Type:Organization
Organization Name:PRIMA MEDICAL GROUP-TERRA LINDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CRISTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-884-1840
Mailing Address - Street 1:4 HAMILTON LANDING
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949
Mailing Address - Country:US
Mailing Address - Phone:415-884-1840
Mailing Address - Fax:415-884-3510
Practice Address - Street 1:4000 CIVIC CENTER DRIVE
Practice Address - Street 2:SUITE 200B
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-492-3333
Practice Address - Fax:415-492-3425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMA MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-03
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73451208D00000X
CAG55637261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA222035382Medicare Oscar/Certification