Basic Information
| Provider Information | |||||||||
| NPI: | 1457336273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCRIPPS CLINIC MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE# 54433 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587845906 | ||||||||
| FaxNumber: | 8587845922 | ||||||||
| Practice Location | |||||||||
| Address1: | 7565 MISSION VALLEY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921084431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192452350 | ||||||||
| FaxNumber: | 6192452390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | SARNOFF | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8585548862 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | GR0013263 | 05 | CA | MEDICAID | C40904 | 01 | RAILROAD MEDICARE | OTHER | ZZZ21938Z | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |