Provider Demographics
NPI:1245429828
Name:SOUTH BAY INTERNAL MEDICAL GRP INC
Entity Type:Organization
Organization Name:SOUTH BAY INTERNAL MEDICAL GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-425-9802
Mailing Address - Street 1:480 4TH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4412
Mailing Address - Country:US
Mailing Address - Phone:619-425-9802
Mailing Address - Fax:619-425-1488
Practice Address - Street 1:480 4TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4412
Practice Address - Country:US
Practice Address - Phone:619-425-9802
Practice Address - Fax:619-425-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20713173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW681Medicare PIN
CAA82270Medicare UPIN