Provider Demographics
NPI:1023388113
Name:HOSPITAL PSYCHIATRIC AND MEDICAL GROUP
Entity Type:Organization
Organization Name:HOSPITAL PSYCHIATRIC AND MEDICAL GROUP
Other - Org Name:HOSPITAL PSYCHIATRIC AND MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:MARKOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-481-0412
Mailing Address - Street 1:3830 VALLEY CENTRE DR
Mailing Address - Street 2:SUITE 705-463
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3320
Mailing Address - Country:US
Mailing Address - Phone:858-481-0412
Mailing Address - Fax:858-481-6066
Practice Address - Street 1:3830 VALLEY CENTRE DR
Practice Address - Street 2:SUITE 705-463
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3320
Practice Address - Country:US
Practice Address - Phone:858-481-0412
Practice Address - Fax:858-481-6066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G346870Medicaid
CAG346870OtherLICENSE
CAW7278OtherGROUP NUMBER
CAG346870OtherLICENSE