Basic Information
| Provider Information | |||||||||
| NPI: | 1568577997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAY AREA PEDIATRIC PULMONARY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 747 52ND ST | ||||||||
| Address2: | SUITE 5409 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283305 | ||||||||
| FaxNumber: | 5105977154 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 52ND ST | ||||||||
| Address2: | SUITE 5409 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283305 | ||||||||
| FaxNumber: | 5105977154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 06/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5104283885 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ64422Z | 01 | CA | BLUE SHIELD PROVIDER NUMB | OTHER | GR0085560 | 05 | CA | MEDICAID | ZZZ60449Z | 01 | CA | BLUE SHIELD PROVIDER NUMB | OTHER | ZZZ60448Z | 01 | CA | BLUE SHIELD PROVIDER NUMB | OTHER | GR0085561 | 05 | CA | MEDICAID |