Provider Demographics
NPI:1720265937
Name:PETER A VON ROGOV MDA PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PETER A VON ROGOV MDA PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:VON ROGOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-749-5743
Mailing Address - Street 1:2100 WEBSTER ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115
Mailing Address - Country:US
Mailing Address - Phone:415-749-5743
Mailing Address - Fax:415-673-4971
Practice Address - Street 1:2100 WEBSTER ST STE 300
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-749-5743
Practice Address - Fax:415-673-4971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23061207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014400Medicaid
ZZZ93109ZMedicare PIN
CAA23382Medicare UPIN