Basic Information
| Provider Information | |||||||||
| NPI: | 1457457608 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE ASSOCIATES OF BERKELEY, A MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1440 | ||||||||
| Address2: | |||||||||
| City: | SUISUN CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945854440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154933300 | ||||||||
| FaxNumber: | 4154933301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320 WOOLSEY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947051973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108438002 | ||||||||
| FaxNumber: | 5105404808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | JAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5108438002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ZZZ27095Z | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0103300 | 01 | CA | MEDICAL | OTHER |