Basic Information
| Provider Information | |||||||||
| NPI: | 1821167628 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINIMALLY INVASIVE SURGICAL SOLUTIONS MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 N BASCOM AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951281811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089180405 | ||||||||
| FaxNumber: | 4089180409 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 N. BASCOM AVE | ||||||||
| Address2: | 104 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951281633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089180405 | ||||||||
| FaxNumber: | 4089180409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | QUEVEDO | ||||||||
| AuthorizedOfficialFirstName: | RIKKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCIAL AND CREDENTIALING COORDIN | ||||||||
| AuthorizedOfficialTelephone: | 4089180405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | G74857 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0095460 | 05 | CA | MEDICAID |