1538226006 NPI number — CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF NEPH

Table of content: (NPI 1538226006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538226006 NPI number — CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF NEPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF NEPH
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:
CHILDREN'S ASSOCIATED MEDICAL GROUP
Provider Other Organization Name Type Code:
4
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:
1538226006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3860 CALLE FORTUNADA
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-4800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-309-6303
Provider Business Mailing Address Fax Number:
858-309-6301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8110 BIRMINGHAM WAY
Provider Second Line Business Practice Location Address:
BUILDING 28
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-2758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-966-8052
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIMMONS
Authorized Official First Name:
HERBERT
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-966-8567

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0210X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0068869 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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