Basic Information
| Provider Information | |||||||||
| NPI: | 1609888593 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION PEAK ORTHOPAEDIC MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39350 CIVIC CENTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945382331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107973933 | ||||||||
| FaxNumber: | 5107975184 | ||||||||
| Practice Location | |||||||||
| Address1: | 39350 CIVIC CENTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945382331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107973933 | ||||||||
| FaxNumber: | 5107975184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | MEMULA | ||||||||
| AuthorizedOfficialFirstName: | LINGAGOUD | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5108182011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A698780 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208100000X | A81391 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | A81391 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 363A00000X | PA17256 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA17256 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | A657720 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZZZ5427Z | 01 | CA | BLUE SHIELD | OTHER |