Basic Information
| Provider Information | |||||||||
| NPI: | 1588039614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN MUIR PHYSICIAN NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 2485 HIGH SCHOOL AVE | ||||||||
| Address2: | #100 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945201819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256710610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2015 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUSKINS | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CAO | ||||||||
| AuthorizedOfficialTelephone: | 9259522888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.