1609190529 NPI number — PACIFIC NEPHROLOGY GROUP A PROFESSIONAL MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609190529 NPI number — PACIFIC NEPHROLOGY GROUP A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC NEPHROLOGY GROUP A PROFESSIONAL MEDICAL CORPORATION
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:
1609190529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
995 GATEWAY CENTER WAY
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92102-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-219-1161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
182 INDUSTRIAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ROCK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17327-8626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-235-9352
Provider Business Practice Location Address Fax Number:
717-235-4024
Provider Enumeration Date:
03/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ISHAK
Authorized Official First Name:
SALAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
619-219-1161

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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