Provider Demographics
NPI:1093882359
Name:CASSIDY MEDICAL GROUP - SW
Entity Type:Organization
Organization Name:CASSIDY MEDICAL GROUP - SW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-630-5487
Mailing Address - Street 1:2095 W VISTA WAY STE 218
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6029
Mailing Address - Country:US
Mailing Address - Phone:760-630-3562
Mailing Address - Fax:760-630-2559
Practice Address - Street 1:2095 W VISTA WAY STE 218
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6029
Practice Address - Country:US
Practice Address - Phone:760-630-3562
Practice Address - Fax:760-630-2559
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASSIDY MEDICAL GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-29
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3016OtherNEIC SITE ID, NSF BA0-7
CAGROO60602Medicaid
CAW14833BMedicare PIN
CAGROO60602Medicaid