Basic Information
| Provider Information | |||||||||
| NPI: | 1376834077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY COMPREHENSIVE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 181770 | ||||||||
| Address2: | |||||||||
| City: | CORONADO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921781770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192641934 | ||||||||
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| Practice Location | |||||||||
| Address1: | 995 GATEWAY CENTER WAY STE 105 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192641934 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2011 | ||||||||
| LastUpdateDate: | 04/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | HASSANEIN | ||||||||
| AuthorizedOfficialFirstName: | TAREK | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 6192641934 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | A54452 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
No ID Information.