Provider Demographics
NPI:1477644474
Name:SCRIPPS MERCY PHYSICIANS CARDIOLOGY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SCRIPPS MERCY PHYSICIANS CARDIOLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-344-3411
Mailing Address - Street 1:550 WASHINGTON ST
Mailing Address - Street 2:SUITE 841
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2213
Mailing Address - Country:US
Mailing Address - Phone:619-359-6600
Mailing Address - Fax:619-632-5736
Practice Address - Street 1:4077 FIFTH AVENUE
Practice Address - Street 2:SCRIPPS MERCY HOSPITAL
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-359-6600
Practice Address - Fax:619-632-5736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2056037OtherMEDICAL
W18875Medicare ID - Type Unspecified