Basic Information
| Provider Information | |||||||||
| NPI: | 1679642904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONTRA COSTA COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONTRA COSTA REGIONAL MEDICAL CENTER EMERGENCY DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 DOUGLAS DR | ||||||||
| Address2: | SUITE 391 | ||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945534098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259575429 | ||||||||
| FaxNumber: | 9259575401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ALHAMBRA AVE | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945533156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259575429 | ||||||||
| FaxNumber: | 9259575401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GODLEY | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO CFO | ||||||||
| AuthorizedOfficialTelephone: | 9259575405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC40276F | 05 | CA | MEDICAID |