Provider Demographics
NPI:1760710396
Name:SOUTH BAY BARIATRICS MEDICAL CORPORATION PC
Entity Type:Organization
Organization Name:SOUTH BAY BARIATRICS MEDICAL CORPORATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:MCKEEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:408-402-9911
Mailing Address - Street 1:2505 SAMARITAN DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4006
Mailing Address - Country:US
Mailing Address - Phone:408-402-9911
Mailing Address - Fax:408-402-9901
Practice Address - Street 1:2505 SAMARITAN DR
Practice Address - Street 2:SUITE 600
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4006
Practice Address - Country:US
Practice Address - Phone:408-402-9911
Practice Address - Fax:408-402-9901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51274208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty