Provider Demographics
NPI:1952656050
Name:GOLDEN STATE ORTHOPEDICS & SPINE
Entity Type:Organization
Organization Name:GOLDEN STATE ORTHOPEDICS & SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:K.C.
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-210-8573
Mailing Address - Street 1:PO BOX 31396
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-8396
Mailing Address - Country:US
Mailing Address - Phone:925-939-8585
Mailing Address - Fax:925-933-2709
Practice Address - Street 1:5201 NORRIS CANYON RD STE 300
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5405
Practice Address - Country:US
Practice Address - Phone:925-939-8585
Practice Address - Fax:925-933-2709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOLDEN STATE ORTHOPEDICS & SPINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-16
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6461930002OtherDME SUPPLIER PTAN
CAZZZ26323ZMedicare PIN