Provider Demographics
NPI:1477908507
Name:SCRIPPS PSYCHIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:SCRIPPS PSYCHIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURANCE
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:CRACROFT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-359-6600
Mailing Address - Street 1:550 WASHINGTON ST STE 841
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2232
Mailing Address - Country:US
Mailing Address - Phone:619-359-6600
Mailing Address - Fax:619-632-5736
Practice Address - Street 1:4077 FIFTH AVE
Practice Address - Street 2:SCRIPPS MERCY HOSPITAL
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
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:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG285872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty