Provider Demographics
NPI:1215003470
Name:CASSIDY MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:CASSIDY MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-630-5487
Mailing Address - Street 1:145 THUNDER DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6010
Mailing Address - Country:US
Mailing Address - Phone:760-630-5487
Mailing Address - Fax:760-630-2558
Practice Address - Street 1:145 THUNDER DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6010
Practice Address - Country:US
Practice Address - Phone:760-630-5487
Practice Address - Fax:760-630-2558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA366026600OtherDEPARTMENT OF LABOR ID
CAGR0060600Medicaid
CA3000OtherNEIC SITE ID, NSF BA0-7
CAZZZ59748ZOtherBLUE CROSS BLUE SHIELD ID
CACAME25OtherUNIVERSAL ID
CACAME25OtherUNIVERSAL ID
CAGR0060600Medicaid
CAW14833BMedicare PIN
CACH4627Medicare PIN
CAZZZ59748ZOtherBLUE CROSS BLUE SHIELD ID
CA366026600OtherDEPARTMENT OF LABOR ID