Provider Demographics
NPI:1508091307
Name:MEDAID CENTER
Entity Type:Organization
Organization Name:MEDAID CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-405-9653
Mailing Address - Street 1:5580 LA JOLLA BLVD
Mailing Address - Street 2:SUITE 611
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5580 LA JOLLA BLVD
Practice Address - Street 2:SUITE 611
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7651
Practice Address - Country:US
Practice Address - Phone:858-405-9653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50464207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA233AMedicare PIN