Provider Demographics
NPI:1275546095
Name:PEDIATRIC MEDICAL ASSOCIATES OF TRI-CITY, INC.
Entity Type:Organization
Organization Name:PEDIATRIC MEDICAL ASSOCIATES OF TRI-CITY, INC.
Other - Org Name:PEDIATRIC MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-945-3434
Mailing Address - Street 1:2067 W VISTA WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6031
Mailing Address - Country:US
Mailing Address - Phone:760-945-3434
Mailing Address - Fax:760-945-6761
Practice Address - Street 1:2067 W VISTA WAY
Practice Address - Street 2:SUITE 180
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6031
Practice Address - Country:US
Practice Address - Phone:760-945-3434
Practice Address - Fax:760-945-6761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0092060Medicaid