Basic Information
| Provider Information | |||||||||
| NPI: | 1316997505 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALBOA NEPHROLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 EXECUTIVE SQ STE 450 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920378411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588100000 | ||||||||
| FaxNumber: | 8582681911 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 EXECUTIVE SQ STE 450 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920378411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588108000 | ||||||||
| FaxNumber: | 8582681911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | EDELSTEIN | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8588108000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 204F00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ04938Z | 01 | CA | MEDICARE PTAN, NO CA | OTHER | W1487 | 01 | CA | MEDICARE PTAN, SO CA | OTHER | CB251966 | 01 | CA | MEDICARE PTAN ORANGE COUNTY | OTHER |