Provider Demographics
NPI:1366606766
Name:PRIMA MEDICAL FOUNDATION
Entity type:Organization
Organization Name:PRIMA MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CRISTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-884-1840
Mailing Address - Street 1:4 HAMILTON LANDING
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949
Mailing Address - Country:US
Mailing Address - Phone:415-884-1840
Mailing Address - Fax:415-884-3510
Practice Address - Street 1:655 REDWOOD HIGHWAY
Practice Address - Street 2:SUITE 216
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:US
Practice Address - Phone:415-383-3500
Practice Address - Fax:415-383-3554
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMA MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-15
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55637208000000X
CAA65187208600000X
208D00000X
CAA77821208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA222035382Medicare Oscar/Certification