Basic Information
| Provider Information | |||||||||
| NPI: | 1407913973 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF ENT | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHILDREN'S ASSOCIATED MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3860 CALLE FORTUNADA | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096303 | ||||||||
| FaxNumber: | 8583096301 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 CHILDRENS WAY | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583097701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIMMONS | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8589668567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S SPECIALISTS OF SAN DIEGO | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | GR006886F | 05 | CA | MEDICAID |