Basic Information
| Provider Information | |||||||||
| NPI: | 1215574462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARBON HEALTH MEDICAL GROUP OF CALIFORNIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 TELEGRAPH AVE | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106863621 | ||||||||
| FaxNumber: | 8889721912 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 TRAVIS BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945334654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076247400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2019 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | PAPA | ||||||||
| AuthorizedOfficialFirstName: | GIANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6178941718 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARBON HEALTH MEDICAL GROUP OF CALIFORNIA PC | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.