Basic Information
| Provider Information | |||||||||
| NPI: | 1417930744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA CANCER CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARIN ONCOLOGY ASSOCIATES; HEMATOLOGY/ONCOLOGY OF THE PENINSULA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 S ELISEO DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159255000 | ||||||||
| FaxNumber: | 4159255050 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 S ELISEO DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159255000 | ||||||||
| FaxNumber: | 4159255050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 11/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | BICHKOFF | ||||||||
| AuthorizedOfficialFirstName: | HARVEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4159255010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0029730 | 05 | CA | MEDICAID |