Basic Information
| Provider Information | |||||||||
| NPI: | 1821431586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAUL PHELPS MD AMC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PAUL R. PHELPS , MD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 969096 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921969096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584950971 | ||||||||
| FaxNumber: | 8584950991 | ||||||||
| Practice Location | |||||||||
| Address1: | 25500 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925625965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519737380 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2013 | ||||||||
| LastUpdateDate: | 04/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8584950971 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G57719 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | G57719 | 01 | CA | LICENSE | OTHER |