Provider Demographics
NPI:1134259542
Name:BAY AREA OBGYN MEDICAL GROUP
Entity type:Organization
Organization Name:BAY AREA OBGYN MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-796-7104
Mailing Address - Street 1:1860 MOWRY AVE # 400
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1722
Mailing Address - Country:US
Mailing Address - Phone:510-796-7104
Mailing Address - Fax:510-794-9783
Practice Address - Street 1:1860 MOWRY AVE
Practice Address - Street 2:# 400
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1730
Practice Address - Country:US
Practice Address - Phone:510-796-7104
Practice Address - Fax:510-793-9783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG772400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G772400Medicare ID - Type Unspecified
CAC74877Medicare UPIN