Provider Demographics
NPI:1679624563
Name:SAN MATEO ORTHOPEDIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:SAN MATEO ORTHOPEDIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAZELRIG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:650-342-0854
Mailing Address - Street 1:77 N SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2889
Mailing Address - Country:US
Mailing Address - Phone:650-342-0854
Mailing Address - Fax:650-342-2198
Practice Address - Street 1:77 N SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2889
Practice Address - Country:US
Practice Address - Phone:650-342-0854
Practice Address - Fax:650-342-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY40773YMedicare UPIN
CAYYY40773YMedicare UPIN