Provider Demographics
NPI:1700967239
Name:ASSOCIATED ORTHOPAEDIC SURGEONS OF HAYWARD
Entity Type:Organization
Organization Name:ASSOCIATED ORTHOPAEDIC SURGEONS OF HAYWARD
Other - Org Name:ASSOCIATED ORTHOPEDIC SURGEONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:T
Authorized Official - Last Name:POTTORFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-886-8844
Mailing Address - Street 1:175 N. REDWOOD DRIVE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1968
Mailing Address - Country:US
Mailing Address - Phone:800-704-0028
Mailing Address - Fax:415-331-8380
Practice Address - Street 1:19842 LAKE CHABOT ROAD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4002
Practice Address - Country:US
Practice Address - Phone:510-886-8844
Practice Address - Fax:510-886-2936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X
CAG61064207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ47993ZMedicare PIN
CAZZZ47993ZMedicare PIN
CA00G634440Medicare PIN