Provider Demographics
NPI:1902903180
Name:PRIMARY PEDIATRIC MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:PRIMARY PEDIATRIC MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-433-1040
Mailing Address - Street 1:PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-0618
Mailing Address - Country:US
Mailing Address - Phone:510-433-1040
Mailing Address - Fax:510-433-1043
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:SUITE 1202
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-433-1040
Practice Address - Fax:510-433-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty