Provider Demographics
NPI:1922361385
Name:AXIOM MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:AXIOM MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:ANATARA MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AHVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERSKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-345-0099
Mailing Address - Street 1:1700 CALIFORNIA ST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4586
Mailing Address - Country:US
Mailing Address - Phone:415-345-0099
Mailing Address - Fax:415-345-0059
Practice Address - Street 1:1700 CALIFORNIA ST
Practice Address - Street 2:SUITE 520
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4586
Practice Address - Country:US
Practice Address - Phone:415-345-0099
Practice Address - Fax:415-345-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50117207R00000X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGJ076AMedicare PIN