Basic Information
| Provider Information | |||||||||
| NPI: | 1609157734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMA MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 HAMILTON LNDG | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949498256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 A DRAKES LANDING RD | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949043119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154617800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2011 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | RUBEL | ||||||||
| AuthorizedOfficialFirstName: | JOANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR OF PRATICE 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 | 208600000X | A65187 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ03538Z | 01 | CA | MEDICARE PTAN | OTHER |