Provider Demographics
NPI:1851664528
Name:MARIN HEALTHCARE DISTRICT
Entity Type:Organization
Organization Name:MARIN HEALTHCARE DISTRICT
Other - Org Name:NORTH MARIN INTERNAL MEDICINE SPECIALISTS
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMANICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-464-2090
Mailing Address - Street 1:PO BOX 45094
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94145-0094
Mailing Address - Country:US
Mailing Address - Phone:415-464-2090
Mailing Address - Fax:415-464-2094
Practice Address - Street 1:165 ROWLAND WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5038
Practice Address - Country:US
Practice Address - Phone:415-897-3174
Practice Address - Fax:415-892-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACS440AOtherMEDICARE GROUP PTAN