Basic Information
Provider Information | |||||||||
NPI: | 1124446158 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALAMEDA HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALAMEDA HOSPITAL PHYSICIANS - A COMMUNITY CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15400 FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | SAN LEANDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 945781009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108957344 | ||||||||
FaxNumber: | 5108957229 | ||||||||
Practice Location | |||||||||
Address1: | 501 S SHORE CTR W | ||||||||
Address2: | SUITE A-F | ||||||||
City: | ALAMEDA | ||||||||
State: | CA | ||||||||
PostalCode: | 945015762 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108144630 | ||||||||
FaxNumber: | 5108144356 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2014 | ||||||||
LastUpdateDate: | 05/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JENSEN | ||||||||
AuthorizedOfficialFirstName: | BERNADETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 5106182147 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.