Basic Information
Provider Information | |||||||||
NPI: | 1982726576 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAY SURGEONS MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1225 MARSHALL ST | ||||||||
Address2: | STE 7 | ||||||||
City: | CRESCENT CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 955312281 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074646372 | ||||||||
FaxNumber: | 7074649593 | ||||||||
Practice Location | |||||||||
Address1: | 3798 JANES RD | ||||||||
Address2: | STE 6 | ||||||||
City: | ARCATA | ||||||||
State: | CA | ||||||||
PostalCode: | 955214753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7078222279 | ||||||||
FaxNumber: | 7074649593 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 11/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KREMEN | ||||||||
AuthorizedOfficialFirstName: | ALAN | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5305324400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 00G569970 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 00G569970 | 05 | CA |   | MEDICAID |