Basic Information
| Provider Information | |||||||||
| NPI: | 1942387188 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAY AREA COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAY AREA COMMUNITY HEALTH - LIBERTY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 40910 FREMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945384375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107708040 | ||||||||
| FaxNumber: | 5106238926 | ||||||||
| Practice Location | |||||||||
| Address1: | 39500 LIBERTY STREET | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945382211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107708040 | ||||||||
| FaxNumber: | 5106238926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAGE | ||||||||
| AuthorizedOfficialFirstName: | ZETTIE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5102526811 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAY AREA COMMUNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD,PH.D,MBA,MSW,MS | ||||||||
| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QF0400X | 140000586 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC70809F | 05 | CA | MEDICAID |