Basic Information
| Provider Information | |||||||||
| NPI: | 1548258106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMA MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949496118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158425000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1260 S ELISEO DR | ||||||||
| Address2: | FLOOR 2 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154617800 | ||||||||
| FaxNumber: | 4159241375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | RUBEL | ||||||||
| AuthorizedOfficialFirstName: | JOANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR OF PRACTICE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4158425103 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMA MEDICAL FOUNDATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207RI0011X | G88295 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RP1001X | G45217 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208D00000X | A72388 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ZZZ03538Z | 01 | CA | MEDICARE | OTHER |