Basic Information
| Provider Information | |||||||||
| NPI: | 1689600314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST BAY AIDS CENTER MEDICAL GROUP,INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SUMMIT ST, 2ND FLOOR | ||||||||
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| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108698488 | ||||||||
| FaxNumber: | 5108698478 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SUMMIT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108698400 | ||||||||
| FaxNumber: | 5108698475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5108698480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LF0000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RI0200X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | GR0087700 | 05 | CA | MEDICAID |