Basic Information
| Provider Information | |||||||||
| NPI: | 1366606766 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMA MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 HAMILTON LANDING | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 REDWOOD HIGHWAY | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | MILL VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153833500 | ||||||||
| FaxNumber: | 4153833554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 08/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | CRISTE | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4158841840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMA MEDICAL FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G55637 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | A65187 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208000000X | A77821 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.