Basic Information
Provider Information | |||||||||
NPI: | 1750001657 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARBON HEALTH MEDICAL GROUP OF CALIFORNIA PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 FRANKLIN ST STE 355 | ||||||||
Address2: |   | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946123140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 46 HILLSDALE MALL | ||||||||
Address2: |   | ||||||||
City: | SAN MATEO | ||||||||
State: | CA | ||||||||
PostalCode: | 944033407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6507695612 | ||||||||
FaxNumber: | 8889721912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2022 | ||||||||
LastUpdateDate: | 10/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAPA | ||||||||
AuthorizedOfficialFirstName: | GIANNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6178941718 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DIRECT URGENT CARE INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.