Provider Demographics
NPI:1780756866
Name:PEDIATRIC MEDICAL ASSOCIATES OF EAST BAY
Entity type:Organization
Organization Name:PEDIATRIC MEDICAL ASSOCIATES OF EAST BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-357-7077
Mailing Address - Street 1:101 CALLAN AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4584
Mailing Address - Country:US
Mailing Address - Phone:510-357-7077
Mailing Address - Fax:510-357-4363
Practice Address - Street 1:101 CALLAN AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4584
Practice Address - Country:US
Practice Address - Phone:510-357-7077
Practice Address - Fax:510-357-4363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0050650Medicaid
CAGR0050651Medicaid