1043699804 NPI number — SYNERGY SPECIALISTS MEDICAL GROUP

Table of content: (NPI 1043699804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043699804 NPI number — SYNERGY SPECIALISTS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYNERGY SPECIALISTS MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043699804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4445 EASTGATE MALL
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92121-1979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-412-6080
Provider Business Mailing Address Fax Number:
858-412-6376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3444 KEARNY VILLA RD STE 401
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-1964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-421-3400
Provider Business Practice Location Address Fax Number:
619-421-3557
Provider Enumeration Date:
05/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DAVID
Authorized Official First Name:
TAL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-571-9500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com