Basic Information
Provider Information | |||||||||
NPI: | 1902438112 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SURGERY CENTER OF SAN DIEGO, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224 N FAIR OAKS AVE STE 300 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911033618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6266961400 | ||||||||
FaxNumber: | 6266961451 | ||||||||
Practice Location | |||||||||
Address1: | 3434 MIDWAY DR STE 1008 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921104924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8584327899 | ||||||||
FaxNumber: | 8584327868 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2020 | ||||||||
LastUpdateDate: | 03/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VARGA | ||||||||
AuthorizedOfficialFirstName: | CLAYTON | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6266961400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 03/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.