Basic Information
| Provider Information | |||||||||
| NPI: | 1659349421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN ELM MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 488 E VALLEY PKWY | ||||||||
| Address2: | 411 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607452000 | ||||||||
| FaxNumber: | 7607450451 | ||||||||
| Practice Location | |||||||||
| Address1: | 488 E VALLEY PKWY | ||||||||
| Address2: | 411 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607452000 | ||||||||
| FaxNumber: | 7607450451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALTSCHULER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7607452000 | ||||||||
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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 | 207Q00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.