Provider Demographics
NPI:1770589418
Name:EAST BAY SPINE SPECIALISTS INC A MEDICAL CORPORATION
Entity type:Organization
Organization Name:EAST BAY SPINE SPECIALISTS INC A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KRULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-469-3120
Mailing Address - Street 1:696 SAN RAMON VALLEY BLVD # 372
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4022
Mailing Address - Country:US
Mailing Address - Phone:925-469-3120
Mailing Address - Fax:925-924-1769
Practice Address - Street 1:5725 W LAS POSITAS BLVD
Practice Address - Street 2:STE 200
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-4007
Practice Address - Country:US
Practice Address - Phone:925-469-3120
Practice Address - Fax:925-924-1769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGROUP208100000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4871030001Medicare NSC