Provider Demographics
NPI:1720083157
Name:REDWOOD PULMONARY MEDICAL ASSOCIATES A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:REDWOOD PULMONARY MEDICAL ASSOCIATES A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:SUSANN
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-367-5636
Mailing Address - Street 1:170 ALAMEDA DE LAS PULGAS
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2751
Mailing Address - Country:US
Mailing Address - Phone:650-367-5636
Mailing Address - Fax:650-367-5110
Practice Address - Street 1:170 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-2751
Practice Address - Country:US
Practice Address - Phone:650-367-5636
Practice Address - Fax:650-367-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74100207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095050Medicaid
CAGR0095050Medicaid