Basic Information
| Provider Information | |||||||||
| NPI: | 1033503446 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMA MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949496118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158425038 | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 ROWLAND WAY | ||||||||
| Address2: | SUITE 275 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949455037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154617800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | FAIRCHILD | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4158425101 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMA MEDICAL FOUNDATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.