Provider Demographics
NPI:1548735202
Name:PROGENY PSYCHIATRIC CLINIC A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PROGENY PSYCHIATRIC CLINIC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:P
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-722-7118
Mailing Address - Street 1:17782 COWAN STE A
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6041
Mailing Address - Country:US
Mailing Address - Phone:949-722-7118
Mailing Address - Fax:949-396-0965
Practice Address - Street 1:17782 COWAN STE A
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6041
Practice Address - Country:US
Practice Address - Phone:949-722-7118
Practice Address - Fax:949-396-0965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-09
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty