Basic Information
Provider Information
NPI: 1376646869
EntityType: 2
ReplacementNPI:  
OrganizationName: REGENTS OF THE UNIVERSITY OF CALIFORNIA - UCSD MEDICAL GROUP
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: UCSD DEPARTMENT OF PAIN MANAGEMENT
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 232410
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921932410
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 200 W ARBOR DR
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921039000
CountryCode: US
TelephoneNumber: 8009268273
FaxNumber: 8885398781
Other Information
ProviderEnumerationDate: 09/07/2006
LastUpdateDate: 02/09/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PRICE
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName: DENNIS
AuthorizedOfficialTitleorPosition: PROVIDER ENROLLMENT
AuthorizedOfficialTelephone: 8582496748
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/09/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207LC0200X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
208VP0014X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
363L00000X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
363LC0200X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
207LP2900X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine

ID Information
IDTypeStateIssuerDescription
36482330301 US DEPT OF LABOROTHER
232701CACMSOTHER
36482330101 DEPT OF LABOROTHER
36482330801 DEPT OF LABOROTHER
36482330001 DEPT OF LABOROTHER
36482330401 US DEPT OF LABOROTHER
CQ402401 RAILROAD MEDICAREOTHER
GR002983005CA MEDICAID
ZZZ25751Z01CABLUE SHIELD- UCSD PAINOTHER
36482330201 US DEPT OF LABOROTHER
36482330601 US DEPT OF LABOROTHER
36482330501 US DEPT OF LABOROTHER
36482330701 DEPT OF LABOROTHER
36482331001 DEPT OF LABOROTHER
CGP01690501CAGHPP GRPOTHER


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