Basic Information
| Provider Information | |||||||||
| NPI: | 1174735005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIN IPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 HAMILTON LANDING #160 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949494949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 HAMILTON LANDING #160 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949494949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CRISTE | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4158841840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.