Basic Information
| Provider Information | |||||||||
| NPI: | 1114942794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUMBACH | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7464 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941207464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152063103 | ||||||||
| FaxNumber: | 4152063872 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 POTRERO AVE | ||||||||
| Address2: | BLDG 80 WARD 83 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152068651 | ||||||||
| FaxNumber: | 4152068387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G59564 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G595640 | 05 | CA | MEDICAID |