Provider Demographics
NPI:1043494651
Name:ASSOCIATED INTERNAL MEDICINE MED GRP INC
Entity type:Organization
Organization Name:ASSOCIATED INTERNAL MEDICINE MED GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:NICKLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-465-6700
Mailing Address - Street 1:350 30TH ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3424
Mailing Address - Country:US
Mailing Address - Phone:510-465-6700
Mailing Address - Fax:510-465-7765
Practice Address - Street 1:100 BAY PL
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4448
Practice Address - Country:US
Practice Address - Phone:510-891-8519
Practice Address - Fax:510-891-8518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84227207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18981ZOtherMEDICARE GROUP NUMBER