Provider Demographics
NPI:1902852510
Name:ROSS VALLEY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ROSS VALLEY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER , CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FLASH
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-461-2262
Mailing Address - Street 1:1000 S. ELISEO DR. STE 204
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904
Mailing Address - Country:US
Mailing Address - Phone:415-461-2262
Mailing Address - Fax:415-461-9376
Practice Address - Street 1:1000 S. ELISEO DR. STE 204
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-461-2262
Practice Address - Fax:415-461-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37304207QA0505X
CAA61715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A47033Medicare UPIN
CAZZZ31139ZMedicare ID - Type Unspecified
CA00G373040Medicare Oscar/Certification