Basic Information
| Provider Information | |||||||||
| NPI: | 1093181646 | ||||||||
| 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: | 9259326330 | ||||||||
| FaxNumber: | 9252154540 | ||||||||
| Practice Location | |||||||||
| Address1: | 19842 LAKE CHABOT RD | ||||||||
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| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945464002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108868844 | ||||||||
| FaxNumber: | 5108862936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2015 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | WONDEH | ||||||||
| AuthorizedOfficialFirstName: | INEZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9259488143 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G061064 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1477520096 | 01 | INDIVIDUAL NPI | OTHER | 7360010004 | 01 | NSC MEDICARE | OTHER |