Basic Information
| Provider Information | |||||||||
| NPI: | 1396124574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAY AREA SURGICAL SPECIALISTS INC A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
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| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259488143 | ||||||||
| FaxNumber: | 9252154540 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 COUNTRY HILLS DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945097436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255282663 | ||||||||
| FaxNumber: | 9257572160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | WONDEH | ||||||||
| AuthorizedOfficialFirstName: | INEZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9259488143 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7360010003 | 01 | NSC MEDICARE | OTHER |