Provider Demographics
NPI:1255536173
Name:EMERYVILLE MULTISPECIALTY MEDICAL GROUP PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:EMERYVILLE MULTISPECIALTY MEDICAL GROUP PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-769-1118
Mailing Address - Street 1:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-0173
Mailing Address - Country:US
Mailing Address - Phone:510-769-1118
Mailing Address - Fax:510-769-1119
Practice Address - Street 1:501 S SHORE CTR W
Practice Address - Street 2:SUITE 103C
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5762
Practice Address - Country:US
Practice Address - Phone:510-769-1118
Practice Address - Fax:510-769-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76128202C00000X, 207Q00000X
CAA84509207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A845090Medicare PIN
CAI30803Medicare UPIN
CA00A761280Medicare PIN