Basic Information
| Provider Information | |||||||||
| NPI: | 1275753493 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN MUIR HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JOHN MUIR MEDICAL CENTER WALNUT CREEK NON INVASI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 YGNACIO VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945983122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259393000 | ||||||||
| FaxNumber: | 9259412236 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 YGNACIO VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945983122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259393000 | ||||||||
| FaxNumber: | 9259412236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELCH | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
| AuthorizedOfficialMiddleName: | LEON | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9259412279 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | ZZZA0703Z | 01 | CA | BL SHIELD PROVIDER NUMBER | OTHER | 050180 | 01 | CA | BLUE CROSS PROV NUMBER | OTHER |