Basic Information
Provider Information | |||||||||
NPI: | 1881796811 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGENTS OF THE UNIVERSITY OF CALIFORNIA - UCSD MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UCSD DEPT OF NEUROPHYSIOLOGY | ||||||||
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: | 09/01/2006 | ||||||||
LastUpdateDate: | 02/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRICE | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | DENNIS | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE & OPERATION | ||||||||
AuthorizedOfficialTelephone: | 8582496752 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0005X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurodevelopmental Disabilities | 2084N0600X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
ID | Type | State | Issuer | Description | 364823303 | 01 |   | US DEPT OF LABOR | OTHER | 364823304 | 01 |   | US DEPT OF LABOR | OTHER | 364823308 | 01 |   | US DEPT OF LABOR | OTHER | 364823310 | 01 |   | US DEPT OF LABOR | OTHER | 364823305 | 01 |   | US DEPT OF LABOR | OTHER | 364823307 | 01 |   | US DEPT OF LABOR | OTHER | CGP016905 | 01 |   | GHPP | OTHER | 364823301 | 01 |   | US DEPT OF LABOR | OTHER | 364823302 | 01 |   | US DEPT OF LABOR | OTHER | 364823306 | 01 |   | US DEPT OF LABOR | OTHER | CQ4024 | 01 |   | RAILROAD MEDICARE | OTHER | 2327 | 01 | CA | CMS | OTHER | 364823300 | 01 |   | US DEPT OF LABOR | OTHER | GR0013561 | 05 | CA |   | MEDICAID | ZZZ26233Z | 01 | CA | BLUE SHIELD | OTHER |