Basic Information
| Provider Information | |||||||||
| NPI: | 1710336300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLASS BEACH MEDICAL SERVICES A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5565 CENTERVIEW DR STE 107 | ||||||||
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| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276063563 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6001 NORRIS CANYON RD | ||||||||
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| City: | SAN RAMON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945835400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732511132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9548382371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.