Basic Information
| Provider Information | |||||||||
| NPI: | 1336114495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | UCSF SFGH MEDICAL GROUP DEPT OF PULMONARY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743749 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900743749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155023283 | ||||||||
| FaxNumber: | 4155028175 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 POTRERO AVE | ||||||||
| Address2: | RM 5K1 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6282068314 | ||||||||
| FaxNumber: | 6282068367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR UCSF SFGH CPG BUSINESS | ||||||||
| AuthorizedOfficialTelephone: | 4152068969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | GR0062257 | 05 | CA | MEDICAID |