Basic Information
| Provider Information | |||||||||
| NPI: | 1265503056 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INJURY MANAGEMENT GROUP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACTION THERAPEUTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3B SOUTH LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505835420 | ||||||||
| FaxNumber: | 6505831398 | ||||||||
| Practice Location | |||||||||
| Address1: | 3B SOUTH LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505835420 | ||||||||
| FaxNumber: | 6505831398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKINNER | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6505835420 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ52353Z | 01 | CA | BLUE SHIELD | OTHER |