Provider Demographics
NPI:1770560914
Name:EL CAMINO RENAL MEDICAL GROUP, INC
Entity type:Organization
Organization Name:EL CAMINO RENAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CARRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-988-7944
Mailing Address - Street 1:515 SOUTH DR
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4204
Mailing Address - Country:US
Mailing Address - Phone:650-988-7944
Mailing Address - Fax:650-964-3608
Practice Address - Street 1:515 SOUTH DR
Practice Address - Street 2:SUITE 12
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4204
Practice Address - Country:US
Practice Address - Phone:650-988-7944
Practice Address - Fax:650-964-3608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ77355ZMedicaid
CA1770560914Medicare PIN
ZZZ77355ZMedicare ID - Type Unspecified