Provider Demographics
NPI:1801857396
Name:ASSOCIATED FAMILY PHYSICIANS OF VALLEJO
Entity Type:Organization
Organization Name:ASSOCIATED FAMILY PHYSICIANS OF VALLEJO
Other - Org Name:ASSOCIATED FAMILY PHYSICIANS MEDICAL GROUP OF VALLEJO-BENICA INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:HENNESSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-643-6483
Mailing Address - Street 1:100 HOSPITAL DR
Mailing Address - Street 2:#304
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2580
Mailing Address - Country:US
Mailing Address - Phone:707-643-6483
Mailing Address - Fax:707-643-3028
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:#304
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2580
Practice Address - Country:US
Practice Address - Phone:707-643-6483
Practice Address - Fax:707-643-3028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-01
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41883207Q00000X
CAG67566207Q00000X
CAG64641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48297YMedicare PIN