Basic Information
| Provider Information | |||||||||
| NPI: | 1477571057 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN MUIR PHYSICIAN NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 34929 | ||||||||
| Address2: | P.O. BOX 39000 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941390001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259522828 | ||||||||
| FaxNumber: | 9259522850 | ||||||||
| Practice Location | |||||||||
| Address1: | 3440 HILLCREST AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945318238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257791331 | ||||||||
| FaxNumber: | 9257791585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 06/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | SORENSON | ||||||||
| AuthorizedOfficialFirstName: | M | ||||||||
| AuthorizedOfficialMiddleName: | KATHERINE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT PRACTICE ADM | ||||||||
| AuthorizedOfficialTelephone: | 9259522888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0068754 | 05 | CA | MEDICAID |