Provider Demographics
NPI:1093783045
Name:SOUTHBAY NEUROLOGICAL MED GR
Entity Type:Organization
Organization Name:SOUTHBAY NEUROLOGICAL MED GR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBOA
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:619-585-7227
Mailing Address - Street 1:360 H ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5511
Mailing Address - Country:US
Mailing Address - Phone:619-585-7227
Mailing Address - Fax:619-585-3190
Practice Address - Street 1:360 H ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5511
Practice Address - Country:US
Practice Address - Phone:619-585-7227
Practice Address - Fax:619-585-3190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2084N0400X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066070Medicaid
CAC35563Medicare UPIN
CAW17860Medicare ID - Type UnspecifiedCORPORATION PROVIDER NUMB
CAWA43717DMedicare ID - Type UnspecifiedROBERTO GRATIANNE, M.D.
CAA51715Medicare UPIN
CAWA43717DMedicare ID - Type UnspecifiedROBERTO GRATIANNE, M.D.
CA00A437170Medicaid
CAWG505320Medicare ID - Type UnspecifiedBENA FISHER, M.D.