Organization
IMHOTEP ISSAQUENA MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
OTIS EUGENE ROUNDS MD (PRESIDENT)
(510) 231-0955
Entity
Organization
Contact information
Practice address
2023 VALE RD, SUITE 211, SAN PABLO, CA 94806-3834
(510) 231-0955
(510) 231-0482
Mailing address
2023 VALE RD, SUITE 211, SAN PABLO, CA 94806-3834
(510) 231-0955
(510) 231-0482
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
G37795
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G37795
—
CA
Enumeration date
11/14/2006
Last updated
06/27/2008
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