Basic Information
| Provider Information | |||||||||
| NPI: | 1043699804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYNERGY SPECIALISTS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 EASTGATE MALL | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584126080 | ||||||||
| FaxNumber: | 8584126376 | ||||||||
| Practice Location | |||||||||
| Address1: | 3444 KEARNY VILLA RD STE 401 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194213400 | ||||||||
| FaxNumber: | 6194213557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2015 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | DAVID | ||||||||
| AuthorizedOfficialFirstName: | TAL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8585719500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SYNERGY SPECIALISTS MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.