Provider Demographics
NPI:1184077463
Name:EAST BAY PHYSICIAN'S MEDICAL GROUP
Entity type:Organization
Organization Name:EAST BAY PHYSICIAN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL SERVICES SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:REYMUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-204-6660
Mailing Address - Street 1:5700 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1710
Mailing Address - Country:US
Mailing Address - Phone:510-204-3986
Mailing Address - Fax:510-204-3948
Practice Address - Street 1:5700 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1710
Practice Address - Country:US
Practice Address - Phone:510-204-3986
Practice Address - Fax:510-204-3948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95004006363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty