Provider Demographics
NPI:1437174240
Name:FALLBROOK-RANCHO SURGERY A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FALLBROOK-RANCHO SURGERY A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:NICOLAS
Authorized Official - Last Name:KEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-698-4650
Mailing Address - Street 1:1374 S MISSION RD STE 408
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-4006
Mailing Address - Country:US
Mailing Address - Phone:951-698-4650
Mailing Address - Fax:951-698-4651
Practice Address - Street 1:1617 JOSHUA TREE LN
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-4334
Practice Address - Country:US
Practice Address - Phone:951-698-4650
Practice Address - Fax:951-698-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49687YOtherSOUTHERN BLUE SHIELD
CAZZZ27707ZOtherNORTHERN BLUE SHIELD
CAGR0081510Medicaid
CAYYY49687YOtherSOUTHERN BLUE SHIELD
CAZZZ27707ZMedicare PIN
CAW5802Medicare PIN