Provider Demographics
NPI:1356631972
Name:PEDIATRIC PRIMARY CARE ASSOCIATED MEDICAL GROUP
Entity Type:Organization
Organization Name:PEDIATRIC PRIMARY CARE ASSOCIATED MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-757-1468
Mailing Address - Street 1:550 WASHINGTON ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2213
Mailing Address - Country:US
Mailing Address - Phone:619-757-1468
Mailing Address - Fax:619-243-0722
Practice Address - Street 1:550 WASHINGTON ST
Practice Address - Street 2:STE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2213
Practice Address - Country:US
Practice Address - Phone:619-757-1468
Practice Address - Fax:619-243-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG393080302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization