Provider Demographics
NPI:1477754091
Name:THE HEART CENTER OF SAN DIEGO MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:THE HEART CENTER OF SAN DIEGO MEDICAL GROUP, INC
Other - Org Name:GROSSMONT HEART CENTER MEDICAL GROUP, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:MADOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-667-0708
Mailing Address - Street 1:8851 CENTER DR STE 312
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3050
Mailing Address - Country:US
Mailing Address - Phone:619-667-0708
Mailing Address - Fax:
Practice Address - Street 1:8851 CENTER DR STE 312
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3050
Practice Address - Country:US
Practice Address - Phone:619-667-0708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG040881174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14888Medicare ID - Type Unspecified
CAA48385Medicare UPIN