Basic Information
| Provider Information | |||||||||
| NPI: | 1548536006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDEN MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN LEANDRO HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20103 LAKE CHABOT RD | ||||||||
| Address2: | |||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945465305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105371234 | ||||||||
| FaxNumber: | 5108896506 | ||||||||
| Practice Location | |||||||||
| Address1: | 13855 E 14TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945782611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103576500 | ||||||||
| FaxNumber: | 5106674572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 08/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | BISCHALANEY | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5107272703 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP40264I | 05 | CA | MEDICAID | HSC00264I | 05 | CA | MEDICAID | ZZR00264I | 05 | CA | MEDICAID | 2082793 | 01 | CA | AETNA | OTHER | ZZZ0118Z | 01 | CA | BLUE SHIELD | OTHER |