Provider Demographics
NPI:1821160771
Name:SAN FRANCISCO PENINSULA CARDIOVASCULAR MEDICAL GRP INC
Entity Type:Organization
Organization Name:SAN FRANCISCO PENINSULA CARDIOVASCULAR MEDICAL GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COLMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-991-1085
Mailing Address - Street 1:1500 SOUTHGATE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015
Mailing Address - Country:US
Mailing Address - Phone:650-991-1085
Mailing Address - Fax:650-758-4834
Practice Address - Street 1:1500 SOUTHGATE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015
Practice Address - Country:US
Practice Address - Phone:650-991-3200
Practice Address - Fax:650-991-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26490207RC0000X
CAC32329207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75309ZMedicaid
CA=========OtherTAX ID NUMBER
A34898Medicare UPIN
CA=========OtherTAX ID NUMBER
CAZZZ75309ZMedicare ID - Type Unspecified