Basic Information
| Provider Information | |||||||||
| NPI: | 1649226242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST BAY ANESTHESIOLOGY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 COLBY ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106660854 | ||||||||
| FaxNumber: | 5106661192 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106554000 | ||||||||
| FaxNumber: | 5108698906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | KAO | ||||||||
| AuthorizedOfficialFirstName: | ALEX | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5106660864 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | FR0061120 | 05 | CA | MEDICAID | CD7348 | 01 | CA | RAILROAD MEDICARE | OTHER |