Basic Information
| Provider Information | |||||||||
| NPI: | 1477598894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST BAY PHYSICIANS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 254869 | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958654869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168546634 | ||||||||
| FaxNumber: | 9168546739 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 DAVIS RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ORINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945633031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252542008 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEWOLF | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9252542008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RN0300X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RR0500X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207V00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2084N0400X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0101862 | 05 | CA | MEDICAID | GR0101867 | 05 | CA | MEDICAID | GR0101872 | 05 | CA | MEDICAID | GR0101874 | 05 | CA | MEDICAID | GR0101870 | 05 | CA | MEDICAID | GR0101863 | 05 | CA | MEDICAID | GR0101866 | 05 | CA | MEDICAID | GR0101873 | 05 | CA | MEDICAID | GR0101860 | 05 | CA | MEDICAID | GR0101868 | 05 | CA | MEDICAID | GR0101871 | 05 | CA | MEDICAID | GR0101861 | 05 | CA | MEDICAID | GR0101864 | 05 | CA | MEDICAID | GR0101865 | 05 | CA | MEDICAID | GR0101869 | 05 | CA | MEDICAID | GR0101875 | 05 | CA | MEDICAID | GR0101876 | 05 | CA | MEDICAID |