Basic Information
| Provider Information | |||||||||
| NPI: | 1689858748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST BAY SURGICAL ASSOCIATES, A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3903 LONE TREE WAY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945096249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257570800 | ||||||||
| FaxNumber: | 9257572160 | ||||||||
| Practice Location | |||||||||
| Address1: | 3903 LONE TREE WAY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945096249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257570800 | ||||||||
| FaxNumber: | 9257572160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | POLIDO | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | W.T. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9257570800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.