Provider Demographics
| NPI: | 1366685737 |
|---|---|
| Name: | PARK TERRACE MEDICAL ASSOCIATES INC |
| Entity Type: | Organization |
| Organization Name: | PARK TERRACE MEDICAL ASSOCIATES INC |
| Other - Org Name: | CENTRE FOR HEALTHCARE |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | MEDICAL DIRECTOR |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | LAWRENCE |
| Authorized Official - Middle Name: | ANDREW |
| Authorized Official - Last Name: | KOENIG |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 858-613-8900 |
| Mailing Address - Street 1: | 15611 POMERADO RD |
| Mailing Address - Street 2: | SUITE 400 |
| Mailing Address - City: | POWAY |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 92064-2437 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 858-613-8900 |
| Mailing Address - Fax: | 858-618-1523 |
| Practice Address - Street 1: | 15611 POMERADO RD |
| Practice Address - Street 2: | SUITE 400 |
| Practice Address - City: | POWAY |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 92064-2437 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 858-613-8900 |
| Practice Address - Fax: | 858-618-1523 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | YES |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2009-04-14 |
| Last Update Date: | 2009-04-14 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
| No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207YS0012X | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine | Group - Multi-Specialty |
| No | 207YX0905X | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | 5254950001 | Medicare NSC | |
| CA | CU0284 | Medicare PIN |
