1821431586 NPI number — PAUL PHELPS MD AMC

Table of content: (NPI 1821431586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821431586 NPI number — PAUL PHELPS MD AMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL PHELPS MD AMC
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:
PAUL R. PHELPS , MD
Provider Other Organization Name Type Code:
5
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:
1821431586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 969096
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92196-9096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-495-0971
Provider Business Mailing Address Fax Number:
858-495-0991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25500 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92562-5965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-973-7380
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHELPS
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-495-0971

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  G57719 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G57719 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".