Provider Demographics
NPI:1417059874
Name:REGENTS OF THE UNVIERSITY OF CALIFONRIA - UCSD MEDICAL GROUP
Entity Type:Organization
Organization Name:REGENTS OF THE UNVIERSITY OF CALIFONRIA - UCSD MEDICAL GROUP
Other - Org Name:UCSD DEPT OF PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR,REVENUE CYCLE & OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-249-6752
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:888-539-8781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ73229ZOtherBLUE SHIELD
364823303OtherUS DEPT OF LABOR
364823300OtherUS DEPT OF LABOR
364823304OtherUS DEPT OF LABOR
364823308OtherUS DEPT OF LABOR
CQ4024OtherRAILROAD MEDICARE
364823305OtherUS DEPT OF LABOR
364823310OtherUS DEPT OF LABOR
CACGP016905OtherGHPP
364823301OtherUS DEPT OF LABOR
364823307OtherUS DEPT OF LABOR
CAGPS000030Medicaid
364823302OtherUS DEPT OF LABOR
364823306OtherUS DEPT OF LABOR
CAZZZP3711ZOtherBLUE SHIELD
364823308OtherUS DEPT OF LABOR
CAGPS000030Medicaid