Basic Information
| Provider Information | |||||||||
| NPI: | 1881884310 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY SPORTS AND FAMILY MEDICINE, A MEDICAL CORPORATION | ||||||||
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| OtherOrganizationName: | SBSFM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 E HACIENDA AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950086616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083763350 | ||||||||
| FaxNumber: | 4083744130 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 E HACIENDA AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950086616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083763350 | ||||||||
| FaxNumber: | 4083744130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 08/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | FULMER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4085682641 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | ZZZ06553Z | 01 | CA | MEDICARE PTAN | OTHER |