Basic Information
| Provider Information | |||||||||
| NPI: | 1649551201 | ||||||||
| 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: | 651 1ST ST W | ||||||||
| Address2: | SUITE K | ||||||||
| City: | SONOMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954767045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079383870 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2011 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | CRISTE | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4158841840 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMA MEDICAL FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G88678 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZZZ03538Z | 01 | CA | MEDICARE PTAN | OTHER |