Basic Information
| Provider Information | |||||||||
| NPI: | 1033667654 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAY AREA SURGICAL SPECIALISTS, INC A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
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| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259488143 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1081 MARKET PL STE 200 | ||||||||
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| City: | SAN RAMON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945834749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258668800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2016 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | WONDEH | ||||||||
| AuthorizedOfficialFirstName: | INEZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9259488143 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 7360010009 | 01 | NSC MEDICARE | OTHER |