Basic Information
| Provider Information | |||||||||
| NPI: | 1558309377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCAFFREY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4551 GLENCOE AVE | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | MARINA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902926385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103012030 | ||||||||
| FaxNumber: | 3103065247 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 E 4TH ST | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194704321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G52216 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930073893 | 01 | RAILROAD MEDICARE | OTHER | 00G522160 | 05 | CA | MEDICAID | G52216 | 01 | BC OF CA | OTHER |