Provider Demographics
NPI:1861503351
Name:EAST BAY VASCULAR MEDICAL GROUP
Entity Type:Organization
Organization Name:EAST BAY VASCULAR MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCI
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-832-6131
Mailing Address - Street 1:365 HAWTHORNE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3107
Mailing Address - Country:US
Mailing Address - Phone:510-832-6131
Mailing Address - Fax:
Practice Address - Street 1:365 HAWTHORNE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3107
Practice Address - Country:US
Practice Address - Phone:510-832-6131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ82873ZMedicaid
CACP6153Medicare PIN
CAZZZ82873ZMedicare PIN