Provider Demographics
NPI:1033289574
Name:SOUTH BAY SKIN & CANCER MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SOUTH BAY SKIN & CANCER MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:RULLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-426-9600
Mailing Address - Street 1:256 LANDIS AVE
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2650
Mailing Address - Country:US
Mailing Address - Phone:619-426-9600
Mailing Address - Fax:619-426-4112
Practice Address - Street 1:256 LANDIS AVE
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2650
Practice Address - Country:US
Practice Address - Phone:619-426-9600
Practice Address - Fax:619-426-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42243207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ73699ZMedicaid
CAA89753Medicare UPIN
CAW1051Medicare PIN