Provider Demographics
NPI:1821167628
Name:MINIMALLY INVASIVE SURGICAL SOLUTIONS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE SURGICAL SOLUTIONS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-918-0405
Mailing Address - Street 1:105 N BASCOM AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1811
Mailing Address - Country:US
Mailing Address - Phone:408-918-0405
Mailing Address - Fax:408-918-0409
Practice Address - Street 1:105 N BASCOM AVE STE 104
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1811
Practice Address - Country:US
Practice Address - Phone:408-918-0405
Practice Address - Fax:408-918-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095460Medicaid
CAGR0095460Medicaid