Basic Information
| Provider Information | |||||||||
| NPI: | 1417179821 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EILEEN T. CONSORTI, MD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3669 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954023669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075354330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 COLBY ST | ||||||||
| Address2: | #201 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108481800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 02/17/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONSORTI | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5108481800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G865870 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.