Basic Information
| Provider Information | |||||||||
| NPI: | 1154418093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILLS PENINSULA HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BURLINGAME DYALISIS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60000 FILE #73688 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506965400 | ||||||||
| FaxNumber: | 6506523051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940103224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506965400 | ||||||||
| FaxNumber: | 6506523051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 04/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERWIN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6506965400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MILLS PENINSULA HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 053516 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | CDC03516F | 05 | CA | MEDICAID |