Provider Demographics
NPI:1164510350
Name:SCRIPPS PLASTIC SURGERY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SCRIPPS PLASTIC SURGERY MEDICAL GROUP INC
Other - Org Name:O GLYNN BOLITHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:GLYNN
Authorized Official - Last Name:BOLITHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:858-458-5100
Mailing Address - Street 1:9834 GENESEE AVE
Mailing Address - Street 2:#311
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-458-5100
Mailing Address - Fax:858-458-1550
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:#311
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-458-5100
Practice Address - Fax:858-458-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69572208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H29631Medicare UPIN