Provider Demographics
NPI:1831381623
Name:SUTTER EAST BAY MEDICAL FOUNDATION
Entity type:Organization
Organization Name:SUTTER EAST BAY MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-962-6613
Mailing Address - Street 1:PO BOX 255789
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5789
Mailing Address - Country:US
Mailing Address - Phone:510-883-9883
Mailing Address - Fax:510-843-0804
Practice Address - Street 1:2850 TELEGRAPH AVENUE
Practice Address - Street 2:SUITE 130
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1159
Practice Address - Country:US
Practice Address - Phone:510-883-9883
Practice Address - Fax:510-843-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLP 326046291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAY764OtherMEDICARE PTAN