Provider Demographics
NPI:1912958422
Name:CHABOT NEPHROLOGY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:CHABOT NEPHROLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-351-1669
Mailing Address - Street 1:101 CALLAN AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4584
Mailing Address - Country:US
Mailing Address - Phone:510-351-1663
Mailing Address - Fax:510-351-1035
Practice Address - Street 1:13851 E 14TH ST
Practice Address - Street 2:206
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2631
Practice Address - Country:US
Practice Address - Phone:510-351-9373
Practice Address - Fax:510-351-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0045151Medicaid
CA271955OtherBRENDA PATRICK, NP
CAZZZ05207ZOtherBLUESHIELD
CAGR0045150Medicaid
CAF17801Medicare UPIN
CAZZZ15026ZMedicare ID - Type Unspecified
CAA87467Medicare UPIN
CAZZZ39444ZMedicare ID - Type Unspecified
CAZZZ23336ZMedicare ID - Type Unspecified
CAF10676Medicare UPIN
CAA36698Medicare UPIN
CAZZZ05207ZOtherBLUESHIELD
CAF40770Medicare UPIN
CAA89657Medicare UPIN
CAA45104Medicare UPIN
CAZZZ24181ZMedicare ID - Type Unspecified
CAGR0045151Medicaid