Provider Demographics
NPI:1811475759
Name:UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Entity type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERREL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-476-3625
Mailing Address - Street 1:PO BOX 743749
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-3749
Mailing Address - Country:US
Mailing Address - Phone:415-514-3000
Mailing Address - Fax:415-502-8175
Practice Address - Street 1:1001 POTRERO AVENUE, BLDG 5, ROOM 1N1
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-502-0661
Practice Address - Fax:415-476-6206
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-02
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty