Basic Information
| Provider Information | |||||||||
| NPI: | 1740347210 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF ENDO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S ASSOCIATED MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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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: | 8110 BIRMINGHAM WAY | ||||||||
| Address2: | BUILDING 28 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589664032 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SEGALL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8585761700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | GR006886G | 05 | CA | MEDICAID |