Basic Information
Provider Information | |||||||||
NPI: | 1235200577 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PALO ALTO MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2350 W EL CAMINO REAL | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | MOUNTAIN VIEW | ||||||||
State: | CA | ||||||||
PostalCode: | 940406201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6509343529 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 795 EL CAMINO REAL | ||||||||
Address2: |   | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943012302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6503214121 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2006 | ||||||||
LastUpdateDate: | 04/30/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SLAVIN | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6509347221 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PALO ALTO MEDICAL FOUNDATION FOR HEALTH CARE, RESEARCH AND EDUCATION | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.