Provider Demographics
NPI:1972045144
Name:CARBON HEALTH MEDICAL GROUP OF CALIFORNIA PC
Entity Type:Organization
Organization Name:CARBON HEALTH MEDICAL GROUP OF CALIFORNIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAPA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-446-1733
Mailing Address - Street 1:2920 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2031
Mailing Address - Country:US
Mailing Address - Phone:510-686-3621
Mailing Address - Fax:
Practice Address - Street 1:411 GRAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-5022
Practice Address - Country:US
Practice Address - Phone:510-844-4097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 261QM1300X
CA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care