Provider Demographics
NPI:1700939642
Name:MID-PENINSULA ORTHOPEDIC MEDICAL GROUP, INC
Entity type:Organization
Organization Name:MID-PENINSULA ORTHOPEDIC MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-348-5400
Mailing Address - Street 1:50 S SAN MATEO DR STE 470
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3833
Mailing Address - Country:US
Mailing Address - Phone:650-348-5400
Mailing Address - Fax:650-348-4172
Practice Address - Street 1:50 S SAN MATEO DR STE 470
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3833
Practice Address - Country:US
Practice Address - Phone:650-348-5400
Practice Address - Fax:650-348-4172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG143360207X00000X
CAG84190207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ70163ZMedicare PIN