Provider Demographics
NPI:1720176225
Name:PENINSULA SURGICAL SPECIALIST MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PENINSULA SURGICAL SPECIALIST MEDICAL GROUP, INC.
Other - Org Name:SURGICAL ASSOCIATES OF THE PENINSULA A MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-777-4064
Mailing Address - Street 1:1720 EL CAMINO REAL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3224
Mailing Address - Country:US
Mailing Address - Phone:650-652-0600
Mailing Address - Fax:
Practice Address - Street 1:1720 EL CAMINO REAL
Practice Address - Street 2:SUITE 101
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3224
Practice Address - Country:US
Practice Address - Phone:650-652-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURGICAL ASSOCIATES OF THE PENINSULA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG1015OtherRAILROAD MEDICARE
CAP00411831OtherRAILROAD MEDICARE
CAP00431764OtherRAILROAD MEDICARE
CAP00405374OtherRAILROAD MEDICARE
CAA42871Medicare UPIN
CAH68316Medicare UPIN
CACG1015OtherRAILROAD MEDICARE
CAF56845Medicare UPIN
CA00A916790Medicare PIN
CAF88243Medicare UPIN
CAA44584Medicare UPIN
CAP00405374OtherRAILROAD MEDICARE
CAP00411831OtherRAILROAD MEDICARE
CAF82459Medicare UPIN
CAF94963Medicare UPIN
CAA40184Medicare UPIN
CAZZZ38666ZMedicare ID - Type Unspecified