Provider Demographics
NPI:1275689994
Name:NATHANIEL G. ROSE, M.D., A.P.C.
Entity Type:Organization
Organization Name:NATHANIEL G. ROSE, M.D., A.P.C.
Other - Org Name:DBA PACIFIC BEACH URGENT CARE MED. GRP.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LALO
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-274-9116
Mailing Address - Street 1:4490 FANUEL ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4292
Mailing Address - Country:US
Mailing Address - Phone:858-274-9116
Mailing Address - Fax:858-490-5321
Practice Address - Street 1:4490 FANUEL ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4292
Practice Address - Country:US
Practice Address - Phone:858-274-9116
Practice Address - Fax:858-490-5321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW7799Medicare PIN