Provider Demographics
NPI:1871731299
Name:EAST BAY SPECIAL IMAGING MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:EAST BAY SPECIAL IMAGING MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:HL
Authorized Official - Last Name:CHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-451-6950
Mailing Address - Street 1:PO BOX 1017
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-1017
Mailing Address - Country:US
Mailing Address - Phone:510-587-0650
Mailing Address - Fax:510-587-0649
Practice Address - Street 1:80 GRAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3725
Practice Address - Country:US
Practice Address - Phone:510-587-0650
Practice Address - Fax:510-587-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABT409AMedicare PIN