Basic Information
| Provider Information | |||||||||
| NPI: | 1417059874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENTS OF THE UNVIERSITY OF CALIFONRIA - UCSD MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | UCSD DEPT OF PSYCHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 232410 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921932410 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921039000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009268273 | ||||||||
| FaxNumber: | 8885398781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | DENNIS | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR,REVENUE CYCLE & OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8582496752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ73229Z | 01 | CA | BLUE SHIELD | OTHER | 364823303 | 01 | US DEPT OF LABOR | OTHER | 364823300 | 01 | US DEPT OF LABOR | OTHER | 364823304 | 01 | US DEPT OF LABOR | OTHER | 364823308 | 01 | US DEPT OF LABOR | OTHER | CQ4024 | 01 | RAILROAD MEDICARE | OTHER | 364823305 | 01 | US DEPT OF LABOR | OTHER | 364823310 | 01 | US DEPT OF LABOR | OTHER | CGP016905 | 01 | CA | GHPP | OTHER | 364823301 | 01 | US DEPT OF LABOR | OTHER | 364823307 | 01 | US DEPT OF LABOR | OTHER | GPS000030 | 05 | CA | MEDICAID | 364823302 | 01 | US DEPT OF LABOR | OTHER | 364823306 | 01 | US DEPT OF LABOR | OTHER | ZZZP3711Z | 01 | CA | BLUE SHIELD | OTHER |