Provider Demographics
NPI:1952438251
Name:EAST BAY HEAD & NECK SURGERY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EAST BAY HEAD & NECK SURGERY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KERBAVAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-845-4500
Mailing Address - Street 1:2316 DWIGHT WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704
Mailing Address - Country:US
Mailing Address - Phone:510-845-4500
Mailing Address - Fax:510-845-0360
Practice Address - Street 1:2316 DWIGHT WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2212
Practice Address - Country:US
Practice Address - Phone:510-845-4500
Practice Address - Fax:510-845-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherCORPORATE TAX ID NUMBER