Provider Demographics
NPI:1255369336
Name:EAST BAY RADIATION ONCOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:EAST BAY RADIATION ONCOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:VAN WEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-581-0556
Mailing Address - Street 1:20126 STANTON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5270
Mailing Address - Country:US
Mailing Address - Phone:510-581-0556
Mailing Address - Fax:510-581-2161
Practice Address - Street 1:20126 STANTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5270
Practice Address - Country:US
Practice Address - Phone:510-581-0556
Practice Address - Fax:510-581-2161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4541522Medicaid
CA4541522Medicaid