Basic Information
| Provider Information | |||||||||
| NPI: | 1336416569 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN MUIR HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JOHN MUIR HEALTH - CONCORD CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 TREAT BLVD | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259393000 | ||||||||
| FaxNumber: | 9259412236 | ||||||||
| Practice Location | |||||||||
| Address1: | 2540 EAST ST | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945201906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256828200 | ||||||||
| FaxNumber: | 9256742009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOODY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9259412159 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOHN MUIR HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | 140000285 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.