Basic Information
Provider Information | |||||||||
NPI: | 1891200820 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALAMEDA HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JOHN GEORGE PAVILION - CRISIS STABILIZATION UNIT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15400 FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | SAN LEANDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 945781009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108957344 | ||||||||
FaxNumber: | 5108957229 | ||||||||
Practice Location | |||||||||
Address1: | 2060 FAIRMONT DR | ||||||||
Address2: |   | ||||||||
City: | SAN LEANDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 945781001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103467500 | ||||||||
FaxNumber: | 5103467515 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2017 | ||||||||
LastUpdateDate: | 12/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WONG | ||||||||
AuthorizedOfficialFirstName: | ALEX | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR REIMBURSEMENT ANALYST | ||||||||
AuthorizedOfficialTelephone: | 5106185716 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   |   | Y |   | Hospitals | Psychiatric Hospital |   |
No ID Information.