Basic Information
| Provider Information | |||||||||
| NPI: | 1356585954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO NEONATOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 500507 | ||||||||
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| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921500507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589394185 | ||||||||
| FaxNumber: | 8589394972 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 HEALTH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589394185 | ||||||||
| FaxNumber: | 8589394972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 04/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8589394185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.