Basic Information
| Provider Information | |||||||||
| NPI: | 1609986777 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST BAY CARDIAC SURGERY CENTER MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IVERSON & STANTEN CARDIAC & THORACIC SURGERY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 WEBSTER ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104656600 | ||||||||
| FaxNumber: | 5108390806 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 WEBSTER ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104656600 | ||||||||
| FaxNumber: | 5108390806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | JUNAID | ||||||||
| AuthorizedOfficialMiddleName: | HAMEED | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5104656600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | GR0060340 | 05 | CA | MEDICAID | ZZZ03169Z | 01 | CA | BLUE SHIELD GRP PROVIDER# | OTHER |