Basic Information
Provider Information | |||||||||
NPI: | 1518963693 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFELONG MEDICAL CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BERKELEY PRIMARY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11247 | ||||||||
Address2: |   | ||||||||
City: | BERKELEY | ||||||||
State: | CA | ||||||||
PostalCode: | 947122247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5109814100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2001 DWIGHT WAY | ||||||||
Address2: | RM 1363 | ||||||||
City: | BERKELEY | ||||||||
State: | CA | ||||||||
PostalCode: | 947042608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5102044666 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2005 | ||||||||
LastUpdateDate: | 10/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LYNCH | ||||||||
AuthorizedOfficialFirstName: | MARTY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5109814100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | N/A | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 140000372 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | HAP70474G | 01 | CA | FAMILY PACT | OTHER | FHC70474G | 05 | CA |   | MEDICAID |