Basic Information
| Provider Information | |||||||||
| NPI: | 1679644256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UCSF MEDICAL GROUP BUSINESS SERVICES | ||||||||
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| OtherOrganizationName: | UCSF DERMATOLOGY MED GRP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 DIVISADERO ST | ||||||||
| Address2: | SUITE 625, BOX 1821 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941430001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154764029 | ||||||||
| FaxNumber: | 4154764150 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 PARNASSUS AVE | ||||||||
| Address2: | 316 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941222721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153537800 | ||||||||
| FaxNumber: | 4153537870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHIVERS | ||||||||
| AuthorizedOfficialFirstName: | JED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4154764003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NP0225X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207NS0135X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | GR008428V | 05 | CA | MEDICAID |