Provider Demographics
NPI:1760621528
Name:JOHN MUIR PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:JOHN MUIR PHYSICIAN NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT PRACTICE ADM
Authorized Official - Prefix:
Authorized Official - First Name:MARY KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SORENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-952-2888
Mailing Address - Street 1:DEPT 34929
Mailing Address - Street 2:P.O. BOX 39000
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-0001
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:925-952-2850
Practice Address - Street 1:2400 BALFOUR RD
Practice Address - Street 2:SUITE 229
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-4945
Practice Address - Country:US
Practice Address - Phone:925-308-8113
Practice Address - Fax:925-308-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR006875GMedicaid
CAGR006875GMedicaid