Provider Demographics
NPI:1891706669
Name:TRI VALLEY GASTROENTEROLOGY MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:TRI VALLEY GASTROENTEROLOGY MEDICAL CENTER, INC.
Other - Org Name:TRI VALLEY GASTROENTEROLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-275-9966
Mailing Address - Street 1:5801 NORRIS CANYON RD
Mailing Address - Street 2:STE. 230
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583
Mailing Address - Country:US
Mailing Address - Phone:925-275-9966
Mailing Address - Fax:925-275-9823
Practice Address - Street 1:5801 NORRIS CANYON RD
Practice Address - Street 2:STE. 230
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583
Practice Address - Country:US
Practice Address - Phone:925-275-9966
Practice Address - Fax:925-275-9823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57371ZOtherBC/BS
CA=========OtherTAX ID
CAZZZ57371ZOtherBC/BS