NPIMap

Organization Active NPI

Mission Peak Orthopaedic Medical Group, Inc

  • Orthopaedic Surgery Physician
  • Fremont, CA
National Provider Identifier
1609888593
Registry record updated Aug 26, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopaedic Surgery PhysicianTaxonomy code 207X00000X
License
A657720 Issued in CA
Legal business name
MISSION PEAK ORTHOPAEDIC MEDICAL GROUP, INC
Practice address
39350 Civic Center Dr Ste 300
Fremont, CA 94538-2331
Phone
(510) 797-3933
Fax
(510) 797-5184
NPI assigned
Aug 12, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 26, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lingagoud Memula
Title
Administrator
Phone
(510) 818-2011

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopaedic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207X00000X A657720 CA Primary
Orthopaedic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207X00000X A698780 CA
Physical Medicine & Rehabilitation PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208100000X A81391 CA
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2081P2900X A81391 CA
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X PA17256 CA
Surgical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AS0400X PA17256 CA

Addresses

Primary practice location

39350 Civic Center Dr Ste 300
Fremont, CA 94538-2331

Mailing address

39350 Civic Center Dr Ste 300
Fremont, CA 94538-2331
Phone (510) 797-3933

Other identifiers 1

IdentifierTypeStateIssuer
ZZZ5427ZOtherCABLUE SHIELD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040629000911 CA Part B Supplier - Clinic/Group Practice 9739165705 Receives reassigned benefits from 18 practitioners
Practice locations: Fremont, CA; Hayward, CA; Pleasanton, CA
O20100930049311 CA DME Supplier - Physician - Podiatry 9739165705 Practice locations: Fremont, CA

National Provider Directory

National Provider Directory

Locations

27206 Calaroga Ave
Ste 101
Hayward, CA 94545
Phone (415) 783-9900

5924 Stoneridge Dr
Ste 200
Pleasanton, CA 94588
Phone (925) 846-6200

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155340800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1440547200000",
    "number": "1609888593",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "39350 CIVIC CENTER DR STE 300",
            "city": "FREMONT",
            "state": "CA",
            "postal_code": "945382331",
            "telephone_number": "510-797-3933",
            "fax_number": "510-797-5184"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "39350 CIVIC CENTER DR STE 300",
            "city": "FREMONT",
            "state": "CA",
            "postal_code": "945382331",
            "telephone_number": "510-797-3933",
            "fax_number": "510-797-5184"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSION PEAK ORTHOPAEDIC MEDICAL GROUP, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-12",
        "last_updated": "2015-08-26",
        "status": "A",
        "authorized_official_last_name": "MEMULA",
        "authorized_official_first_name": "LINGAGOUD",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "510-818-2011"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": "CA",
            "license": "A657720",
            "primary": true
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": "CA",
            "license": "A698780",
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "CA",
            "license": "A81391",
            "primary": false
        },
        {
            "code": "2081P2900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": "CA",
            "license": "A81391",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "PA17256",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Surgical",
            "state": "CA",
            "license": "PA17256",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "ZZZ5427Z",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fremont, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.