Basic Information
Provider Information | |||||||||
NPI: | 1578672184 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGENTS OF THE UNIVERSITY OF CALIFORNIA - UCSD MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UCSD DEPARTMENT OF FAMILY MEDICINE, ACUPUNCTURE, UC, EM | ||||||||
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: | 08/29/2006 | ||||||||
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 | 207QG0300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QA0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0401X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207QA0505X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 364823306 | 01 |   | DEPARTMENT OF LABOR | OTHER | 364823310 | 01 |   | DEPARTMENT OF LABOR | OTHER | 364823304 | 01 |   | DEPARTMENT OF LABOR | OTHER | 2327 | 01 | CA | CMS GRP | OTHER | 364823301 | 01 |   | DEPARTMENT OF LABOR | OTHER | 364823305 | 01 | CA | DEPARTMENT OF LABOR | OTHER | 364823307 | 01 |   | DEPARTMENT OF LABOR | OTHER | ZZZP3718Z | 05 | CA |   | MEDICAID | 364823303 | 01 |   | DEPARTMENT OF LABOR | OTHER | 364823300 | 01 |   | DEPARTMENT OF LABOR | OTHER | ZZZP3718Z | 01 | CA | CALOPTIMA | OTHER | CQ4024 | 01 | CA | RAILROAD MEDICARE GRP | OTHER | 364823302 | 01 |   | DEPARTMENT OF LABOR | OTHER | 364823308 | 01 |   | DEPARTEMNT OF LABOR | OTHER | CGP016905 | 01 | CA | GHPP | OTHER | ZZZP3718Z | 01 | CA | BLUE SHIELD | OTHER |