Basic Information
Provider Information | |||||||||
NPI: | 1386762300 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGENTS OF THE UNIVERSITY OF CALIFORNIA-UCSD MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UCSD DEPT OF PULMONARY/CRITICAL CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 03/27/2007 | ||||||||
LastUpdateDate: | 01/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRICE | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | DENNIS | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE & OPERATION | ||||||||
AuthorizedOfficialTelephone: | 8582496752 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | CQ4024 | 01 | CA | RAILROAD MEDICARE | OTHER | GR0013562 | 05 | CA |   | MEDICAID | ZZZP3708Z | 05 | CA |   | MEDICAID |