Provider Demographics
NPI:1548258106
Name:PRIMA MEDICAL FOUNDATION
Entity type:Organization
Organization Name:PRIMA MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR OF PRACTICE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-842-5103
Mailing Address - Street 1:9 COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6118
Mailing Address - Country:US
Mailing Address - Phone:415-842-5000
Mailing Address - Fax:
Practice Address - Street 1:1260 S ELISEO DR
Practice Address - Street 2:FLOOR 2
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2009
Practice Address - Country:US
Practice Address - Phone:415-461-7800
Practice Address - Fax:415-924-1375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMA MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-07
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
CAG88295207RI0011X
CAG45217207RP1001X
CAA72388208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03538ZOtherMEDICARE
CAZZZ03538ZOtherMEDICARE