Provider Demographics
NPI:1275628992
Name:EAST BAY NEPHROLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EAST BAY NEPHROLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-841-0411
Mailing Address - Street 1:2905 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2063
Mailing Address - Country:US
Mailing Address - Phone:510-841-0411
Mailing Address - Fax:510-845-5030
Practice Address - Street 1:14020 SAN PABLO AVE
Practice Address - Street 2:STE A
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3604
Practice Address - Country:US
Practice Address - Phone:510-841-0411
Practice Address - Fax:510-845-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACR0683OtherRAILROAD MEDICARE GROUP #
CAZZZ70798ZMedicaid
CAZZZ70798ZMedicare ID - Type UnspecifiedGROUP NUMBER