Provider Demographics
NPI:1982960084
Name:EAST BAY TRAUMA & ACUTE CARE SURGERY INC.
Entity Type:Organization
Organization Name:EAST BAY TRAUMA & ACUTE CARE SURGERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SABA
Authorized Official - Middle Name:
Authorized Official - Last Name:AZIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-538-5500
Mailing Address - Street 1:19845 LAKE CHABOT ROAD
Mailing Address - Street 2:200
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4055
Mailing Address - Country:US
Mailing Address - Phone:510-538-5500
Mailing Address - Fax:510-538-5505
Practice Address - Street 1:19845 LAKE CHABOT RD
Practice Address - Street 2:200
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4055
Practice Address - Country:US
Practice Address - Phone:510-538-5500
Practice Address - Fax:510-538-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87104174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid