Basic Information
| Provider Information | |||||||||
| NPI: | 1922114131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GROSSMONT OB/GYN MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8851 CENTER DR | ||||||||
| Address2: | STE #500 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194612660 | ||||||||
| FaxNumber: | 6194615760 | ||||||||
| Practice Location | |||||||||
| Address1: | 8851 CENTER DR | ||||||||
| Address2: | STE #500 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194612660 | ||||||||
| FaxNumber: | 6194615760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | GERI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6194612663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | C086184 | 01 | CA | CHAMPUS GROUP I.D. | OTHER | ZZZ47807Z | 01 | CA | MEDI-CAL | OTHER |