Provider Demographics
NPI:1528023306
Name:AMIGO MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:AMIGO MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:MONAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-427-5053
Mailing Address - Street 1:386 E H ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7485
Mailing Address - Country:US
Mailing Address - Phone:619-427-5053
Mailing Address - Fax:619-427-1437
Practice Address - Street 1:386 E H ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7485
Practice Address - Country:US
Practice Address - Phone:619-427-5053
Practice Address - Fax:619-427-1437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP 4774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0046550Medicaid
CAW2818Medicare ID - Type Unspecified