Provider Demographics
NPI:1912186834
Name:BAY AREA COMMITTED TO KIDS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BAY AREA COMMITTED TO KIDS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:WALLACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-336-0880
Mailing Address - Street 1:3306 HERRIER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-4004
Mailing Address - Country:US
Mailing Address - Phone:510-336-0880
Mailing Address - Fax:
Practice Address - Street 1:3306 HERRIER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-4004
Practice Address - Country:US
Practice Address - Phone:510-336-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-27
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79903208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912186834Medicaid