Provider Demographics
NPI:1881734515
Name:EAST BAY GASTROENTEROLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:EAST BAY GASTROENTEROLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-832-2767
Mailing Address - Street 1:350 30TH ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3424
Mailing Address - Country:US
Mailing Address - Phone:510-832-2767
Mailing Address - Fax:510-832-6713
Practice Address - Street 1:350 30TH ST
Practice Address - Street 2:SUITE 305
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3424
Practice Address - Country:US
Practice Address - Phone:510-832-2767
Practice Address - Fax:510-832-6713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22865Medicare UPIN
CAZZZ74476ZMedicare ID - Type Unspecified