Basic Information
| Provider Information | |||||||||
| NPI: | 1770784563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALAMEDA HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEWARK HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15400 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945781009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108957344 | ||||||||
| FaxNumber: | 5108957229 | ||||||||
| Practice Location | |||||||||
| Address1: | 6066 CIVIV TERRACE AVENUE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945603756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105051600 | ||||||||
| FaxNumber: | 5104947210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | PEQUIGNOT | ||||||||
| AuthorizedOfficialFirstName: | MERRILYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIR. PROFESSIONAL REVENUE | ||||||||
| AuthorizedOfficialTelephone: | 5103461349 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | EXEMPT UNDER 12-35B | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | BCP11799G | 05 | CA | MEDICAID |