Basic Information
| Provider Information | |||||||||
| NPI: | 1457533747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE MEDICAL SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4974 EL CAJON BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921154677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192864600 | ||||||||
| FaxNumber: | 6192860060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4974 EL CAJON BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921154677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192864600 | ||||||||
| FaxNumber: | 6192860060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOYLAN | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6192864600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 37-19 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.